What happens after complete withdrawal of therapy in patients with lupus nephritis.

Whether and when is it possible to completely stop immunosuppression in patients with lupus nephritis is still poorly defined.An attempt to slowly and progressively eliminate steroids and immunosuppressive drugs was tried in 73 of 161 (45.3%) patients with lupus nephritis who achieved a stable clinical remission defined as normal serum creatinine, proteinuria <0.5g/24h, inactive urine sediment, and no clinical signs of extra-renal activity of SLE for at least 12 months.Twenty-one out of the 73 patients (28.7%) who met the criteria for withdrawal of treatment developed flares during the phase of progressive reduction of therapy and their treatment was reinforced. Twenty patients entered remission again; the last patient was lost to follow-up at achievement of partial remission. In the other 52 of the 73 patients (71.2%), it was possible to completely withdraw treatment. Of these, 32 patients (group A) did not resume therapy for the subsequent follow-up (median 101.8 months); the other 20 patients (group B) had at least one flare, in median 37 months after withdrawing therapy, and had to be retreated. At the last observation, after a median follow-up of 286 months, 10 of these 20 patients were off therapy. At the last observation, two patients in group A and two in group B had died, no patient of group A and two of group B had developed renal insufficiency (serum creatinine 2.5 and 3 mg/dl, respectively). Compared to patients in group B, group A patients received longer treatment (98.1 vs. 31.0 months; p=0.01), had longer remission (52.8 vs. 12.0 months; p=0.000) before withdrawal of therapy, and continued chloroquine after stopping therapy (52% vs. 10%; p=0.004). In comparison to patients who never stopped therapy, patients who were able to interrupt treatment had lower risk of chronic renal insufficiency (3.8% vs. 28.4%; p=0.000), end-stage renal disease (0 vs. 12.8%; p=0.01), arterial hypertension (32.7% vs. 66.9%; p=0.000) and cardiovascular events (11.5% vs. 27.5%; p=0.04).Complete withdrawal of therapy is feasible in selected patients who achieved stable remission after long-term treatment. The reduction of treatment must be done in a very gradual manner, progressively and under strict medical surveillance. The withdrawal of therapy allows the patients to reduce renal and extra-renal damage accrual. Treatment with chloroquine may help to maintain remission in patients who discontinue steroids and immunosuppressive drugs.