Medium versus high initial prednisone dose for remission induction in lupus nephritis: A propensity score matched analysis
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BACKGROUND: The existing guidelines for lupus nephritis (LN) recommend initial prednisone doses of 0.3-1mg/kg/day. However, recent studies reported non-inferior outcomes with lower doses. The aim of this study was to compare the complete renal response rates in LN patients treated with prednisone ≤30mg/day or ≥40mg/day. PATIENTS-METHODS: Patients with new-onset LN and standard immunosuppressive treatment were followed for at least 12 months, divided into medium (≤30mg/day) and high prednisone groups (≥40mg/day) and matched (propensity score) based on the baseline differences. Complete renal response was defined as proteinuria <0.5g/day and no worsening in renal function. Glucocorticoid-related damage was also assessed. RESULTS: High prednisone patients (n=103, mean dose 48.6±12.3 mg/day) achieved better rates of complete response compared to the medium group (n=103, mean dose 24.2±4.6 mg/day) [61.8% vs. 38.2%, p=0.024] at 12 months. The difference in response rates was reproduced for several subgroups (concomitant immunosuppressive treatment, proliferative/non-proliferative LN). Complete remission rates were higher at two [67.8% vs. 39%, p=0.002] and three years [64.9% vs. 49.1%, p=0.025] after LN diagnosis. Cumulative glucocorticoid dose was comparable at two and three years. Glucocorticoid-related damage was accelerated in both groups for the same period. CONCLUSION: Higher initial prednisone doses (median 45mg/day) achieved significantly better rates of complete renal response at 12 months in new-onset LN. Cumulative glucocorticoid dose and damage accrual was not different at 2 and 3 years after LN. Damage was more prominent in the late phases of LN in both groups, underlining the importance of rapid tapering and the need to implement alternative strategies.
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