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Mycophenolate mofetil following glucocorticoid treatment in Henoch-Schönlein purpura nephritis: the role of early initiation and therapeutic drug monitoring

Authors
  • Hackl, Agnes1
  • Becker, Jan U.2
  • Körner, Lisa M.1
  • Ehren, Rasmus1
  • Habbig, Sandra1
  • Nüsken, Eva1
  • Nüsken, Kai-Dietrich1
  • Ebner, Kathrin1
  • Liebau, Max C.1, 3, 4
  • Müller, Carsten5
  • Pohl, Martin6
  • Weber, Lutz T.1
  • 1 University Hospital of Cologne, Pediatric Nephrology, Children’s and Adolescents’ Hospital, Kerpener Street 62, Cologne, 50937, Germany , Cologne (Germany)
  • 2 University Hospital of Cologne, Institute of Pathology, Cologne, Germany , Cologne (Germany)
  • 3 University Hospital of Cologne, Nephrology Research Laboratory, Department II of Internal Medicine, Cologne, Germany , Cologne (Germany)
  • 4 University Hospital of Cologne, Center for Molecular Medicine, Cologne, Germany , Cologne (Germany)
  • 5 University Hospital of Cologne, Department of Therapeutic Drug Monitoring, Centre of Pharmacology, Cologne, Germany , Cologne (Germany)
  • 6 University of Freiburg Germany, Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - Faculty of Medicine, Freiburg, Germany , Freiburg (Germany)
Type
Published Article
Journal
Pediatric Nephrology
Publisher
Springer-Verlag
Publication Date
Nov 25, 2017
Volume
33
Issue
4
Pages
619–629
Identifiers
DOI: 10.1007/s00467-017-3846-6
Source
Springer Nature
Keywords
License
Yellow

Abstract

BackgroundHenoch-Schönlein purpura (HSP) is the most common vasculitis in childhood and traditionally considered as a self-limiting disease. However, renal involvement can unfavorably determine long-term prognosis. The reported regimens to treat HSP nephritis (HSPN) are diverse, indicating that the most effective treatment remains controversial.MethodsThis retrospective, single-center study involved 18 patients presenting with HSPN and nephrotic-range proteinuria. We aimed to investigate the efficacy and safety of mycophenolate mofetil (MMF) and identify a cut-off level for estimated mycophenolic acid area under the curve (eMPA-AUC0-12h) values, which can predict complete remission with high sensitivity.ResultsDespite prior insufficient therapeutic response to corticosteroids, 89% of patients showed a significant decrease in proteinuria after 1 month of MMF treatment. None of them relapsed during treatment; however, two children relapsed after discontinuation. Based on results of a receiver operating characteristic (ROC) analysis, an eMPA-AUC0–12h >56.4 mg*h/l was a predictor for complete remission within 3 months (80% sensitivity, 83.3% specificity, p = 0.035). During MMF administration, we encountered no adverse event requiring discontinuation of treatment.ConclusionOur study demonstrates that MMF is a safe and potentially effective secondary treatment option for children with HSPN to achieve and maintain long-term remission without serious side effects. To achieve complete remission within 3 months, resolve severe inflammatory glomerular lesions, and avoid progression to chronic kidney disease, we propose timely diagnosis and early initiation of MMF with an eMPA-AUC0–12h value of 56.4 mg*h/l.

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