Background A growing number of women with Lupus nephritis (LN) wish to fulfil their desire for having a child. A common concern is the optimal choice of immunosuppressive treatment during the preconception period in the case of planned pregnancy. Whereas AZA can be used safely during pregnancy, current recommendation is transition from MMF to AZA at least 6 weeks before conception . However, there are few data supporting these recommendations. In particular, any change in medication can induce flares in a patient with otherwise stable disease and such flares may later evolve during pregnancies.
Objectives To evaluate the risk of renal relapse in patients with stable LN who switched from MMF to AZA for planned pregnancy, and to study the frequency and outcome of subsequent pregnancies.
Methods Medical records of women with LN counselled for a pregnancy wish were reviewed. Women receiving treatment with either MMF or AZA (control group), with inactive lupus (SLEDAI ≤ 4) and quiescent LN (serum creatinine < 1.5 mg/dl, inactive sediment and proteinuria <1 g/24-hr for the preceding 6 months) were eligible for this study. MMF dose was tapered and transferred to AZA in case there was no sign of renal or extra renal flare upon this time point. Treatment with AZA was maintained throughout preconception period and pregnancy.
Results We identified 54 women [23 treated with MMF (group 1), 31 treated with AZA (group 2)]. Median duration of MMF treatment was 28 (range 16-96) months. Three patients (group 1) vs none (group 2) developed a renal flare 3-6 months after transitioning from MMF to AZA (p 0.14). The only parameter with significant difference in those with flare compared to those without was younger age (median 27 vs 30 yrs; p 0.03). 48 women conceived during follow up with 91.6 % pregnancies resulting in live birth. Using logistic regression analysis, risk for combined adverse pregnancy outcome (miscarriage, preeclampsia and/or preterm delivery) increased with every mg of prednisone dosage at baseline [OR 2.02 (95% CI 1.19-3.44)] and every single unit of SLEDAI score [OR 3.92 (95% CI 1.18 – 13)]. In addition, risk for adverse pregnancy outcome increased with every year of age [OR 1.31 (95% CI 1.02-1.68]). One woman in each group [5.5 % (group 1) vs. 3.3 % (group 2)] experienced renal flare after delivery, respectively. Both responded to an increase in steroid dose. No patient developed worsening of renal function during a mean follow-up period of 31 (±27) months postpartum.
Conclusions Replacing MMF with AZA in patients with quiescent LN for pregnancy planning rarely leads to renal flares. Pregnancy outcome was favourable. This is of importance for counselling affected women in rheumatologic practice and planning of pregnancies.
Bertsias GK, Tektonidou M, Amoura Z et al. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012 Jul 31.
Disclosure of Interest None Declared