Friday, July 27, 2012
Right treatment for lupus nephritis
Treatment of lupus nephritis need to "match" and other issues of concern are the majority of patients, Shijiazhuang kidney hospital for brief treatment of lupus nephritis need to "match"
Timely treatment is critical to improve the prognosis of patients with lupus nephritis. Traditional medicines in the treatment of lupus nephritis is a hormone, its dosage should be based on the extent of clinical manifestations and histological changes. Clinical practice, the combination of cytotoxic drugs than simply better the effect of hormone therapy. (1) lupus nephritis workers do not require special treatment, follow-up observation. (2) lupus nephritis type Ⅱ Ⅱ a type only some mild mesangial lesions without treatment; Ⅱ b lesions with proteinuria more than] g/24h serum high titers of anti-dsDNA and low C3 complement The hyperlipidemia prednisone 20mg / d, once every six weeks - 3 months, after reduction to maintain. (3) the same lupus nephritis III type and type Ⅳ two types of treatment options, the prognosis is similar. Because the incidence of ESRD in 10 years up to 50% or more, it should strengthen treatment. 1) glucocorticoids: prednisone-based drugs, conventional dosage of 0.8 1mg.kg_1. D_1, eight weeks after treatment began to gradually decrease, the reduction rate must be controlled, maintenance treatment to 10_20mg / d for at least two years . Necessary to give methylprednisolone, 0.75g.m2_1. D_1 intravenous infusion for three consecutive days as a course. Methylprednisolone followed by prednisone maintenance therapy, efficacy, side effects. Need to be adjusted when the following conditions occurs glucocorticoid medication: difficult to control diabetes or high blood pressure, severe osteoporosis, steroid psychosis, severe infection and severe myopathy. 2) cytotoxic drugs: even without cytotoxic drugs, glucocorticoid treatment of proliferative glomerulonephritis, the treatment more fully in combination with cytotoxic drugs, but cytotoxic drugs often take 3-4 months before onset. Cytotoxic drugs in the treatment of the beginning of the application, can also be added with the hormone is not satisfied with the results. Studies have shown that, added to enhance the efficacy of cytotoxic drugs can reduce the hormone dosage. To cyclophosphamide (CTX) pulse therapy, 750mg/M2 in normal saline slow intravenous infusion in more than one hour, 1 time / month, once every six months. The absence of disease activity every three months the impact of a stable after treatment for 1-2 years may be considered withdrawal. Side effects: In addition to the common side effects, but also the occurrence of menstrual disorders (16% -20%), reproductive failure (19%), hemorrhagic cystitis (17%), bladder (2%). Used in conjunction with small doses of glucocorticoids can enhance efficacy and reduce toxicity. CTX medication need to be adjusted in the following circumstances: refractory hemorrhagic cystitis, severe nausea, vomiting, radiotherapy, previous history of cancer, bone marrow suppression caused by reduced blood cell damage resulting from blood (peripheral blood cells decreased excluded). 3) 30% -50% of patients with lupus nephritis poor response to the above treatment, especially nephrotic syndrome. Most of the patients at the onset of treatment of 4-6 months to 9-15 months to the above therapy tolerance. You can take the following measures: ① a monthly infusion of CTX, once every six months, at the same time increase the impact of methylprednisolone; (2) was added azathioprine in combination with prednisone and CTX infusion can also be CTX replaced by small doses of oral; (3) the addition of plasma exchange, carried out simultaneously with the CTX treatment; ④ appropriate to increase the amount of glucocorticoid. 4) lupus acute exacerbation of: deterioration of renal function, methylprednisolone or plasma exchange, which is particularly associated with cryoglobulinemia, hyperviscosity, or thrombotic thrombocytopenic purpura patients. 5) Azathioprine: usually as second-line drugs, wide foreign application that is safer, even pregnancy, the patient only occasionally teratogenic, can delay the progress of chronic kidney damage, the combination allows acute kidney disease and methylprednisolone quickly ease. 6) mycophenolate mofetil (MMF, trade name Cellcept): can be used for the treatment of diffuse proliferative lupus nephritis, at home and abroad has been a small sample of reports, has a certain effect. 7) other immunosuppressive therapy: Methotrexate: 6 months of the glucocorticoid treatment is invalid, the trial of methotrexate 15mg / w. Cyclosporine A: The dose of 2.5-5mg.kg_1. D_1, mainly used in the conventional-therapy patients; main side effects are nephrotoxicity, hypertension and abnormal liver function. Has also started anti-CD4 monoclonal antibody drugs for clinical use. Occasionally also be used chlorambucil, nitrogen mustard or whole lymph node area radiation (TLl) therapy. 8) anticoagulant therapy: dipyridamole 100mg orally, three times the old; 60 000 U of urokinase infusion, 1/14 days for a course; low molecular weight heparin and hirudin treatment also can get better effect. 9) Other treatment: male hormone DHEA (dehydroepiandrosterone androstane ketones), hydroxychloroquine, dopamine antagonists bromoefiptine and 2 - chloro-deoxyadenosine, etc. can achieve a certain effect. The effect of plasma exchange or plasma separation is not ideal and necessary with the immunosuppressive therapy. The autologous bone marrow T-cell reinfusion only individual cases of success. Lupus nephritis in patients with end stage renal failure must be considered a replacement therapy for peritoneal dialysis, hemodialysis, kidney transplantation. (4) lupus nephritis Ⅴ are generally accompanied by varying degrees of proliferative lesions, treatment options, and type IV lupus nephritis. May be prednisone lmg kg_1. D_1 after 6-12 weeks of treatment, was reduced to 10mg / d for 1-2 years. Simple membrane lesions are rare, accounting for only 15% of the cases of renal biopsy in type Ⅴ lupus nephritis. (5) when the patient's serum creatinine long-term to exceed 3mg/dL or long-standing chronic index, you should note the following: ① unless there is a higher activity index, usually do not advocate the use of a strong treatment programs; ② treatment of renal Lupus usually give prednisone 5-10mg / d to maintain; the ③ salt and protein intake should be limited, and to monitor changes in blood pressure.