Calcineurin inhibitors may be a reasonable alternative to cyclophosphamide in the induction treatment of active lupus nephritis: A systematic review and meta-analysis

Although the accepted standard of care during the induction treatment of active lupus nephritis (LN) has been cyclophosphamide (CYC), recent trials suggest that calcineurin inhibitors (CNIs), which include cyclosporine A (CsA) and tacrolimus (TAC), may be just as, or even more, effective and less toxic than CYC. A systematic review and meta-analysis were performed to evaluate the clinical effects of CNIs on active LN compared with those of CYC. In the present study, clinical trials that compared CNIs with CYC in the induction therapy of active LN were searched in the Cochrane Library, Ovid and PubMed databases. The clinical data on renal remission and side-effects were collected and analyzed. The relative risk (RR) and 95% confidence intervals (CIs) were calculated. As a result, six controlled trials involving 265 patients were included in the meta-analysis, four of which compared TAC (treatment group) with CYC (control group), and the other two compared CsA (treatment group) with CYC (control group). CNIs were superior to CYC for higher complete remission (RR=1.56, 95% CI 1.14-2.15, Z=2.74, P=0.006) and better overall response/total remission (RR=1.23, 95% CI 1.07-1.42, Z=2.87, P=0.004) and had fewer side-effects. Among the CNIs, TAC demonstrated more favorable results than CsA. Therefore, it was concluded that CNIs may be a reasonable alternative to CYC in the induction treatment of active LN. However, large-scale, multicenter, well-designed clinical trials should be adopted to further confirm this conclusion.