clinical trial

www.kidney-international.org

Comparison of low-dose intravenous

cyclophosphamide with oral mycophenolate
mofetil in the treatment of lupus nephritis

see commentary on page 25

Manish Rathi1, Ajay Goyal1, Ajay Jaryal1, Aman Sharma2, Pramod K. Gupta3, Raja Ramachandran1,
Vivek Kumar1, Harbir S. Kohli1, Vinay Sakhuja4, Vivekanand Jha1 and Krishan L. Gupta1
1

Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 2Department of Internal
Medicine, Rheumatology Wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 3Department of
Biostatistics, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and 4Department of Nephrology and Renal
Transplant Surgery, Max Super Speciality Hospital, Mohali, India

No previous study has compared mycophenolate mofetil

(MMF) with low-dose cyclophosphamide (CYC) in the
treatment of lupus nephritis (LN). To do so, we recruited
patients with LN (class III, IV, or V) and randomized them to
receive either low-dose CYC or oral MMF. Those with
crescentic LN, a serum creatinine over 265 mmol/l, and
neurological or pulmonary lupus were excluded. MMF was
prescribed at daily doses of 1.53 g for 24 weeks, while CYC
was administered as six fortnightly infusions of 500 mg
each. All patients received three methylprednisolone
injections, followed by oral corticosteroids. Maintenance
therapy with azathioprine and low-dose corticosteroid was
started at end of induction therapy. The primary end point
was treatment response at 24 weeks, while secondary end
points were complete remission, Systemic Lupus
Erythematosus Disease Activity Index and adverse events.
Of the 173 patients recruited, 100 were equally randomized
to receive either CYC or MMF. Baseline characteristics were
similar, except for higher 24 h proteinuria in the CYC group.
At 24 weeks, 37 patients in each group achieved the
primary end point. The complete remission rate was 50% in
CYC and 54% in MMF group. Gastrointestinal symptoms
were signicantly more frequent in patients receiving MMF
(52 vs. 4%). However, other adverse events were similar.
Thus, low-dose intravenous CYC is comparable in safety
and efcacy to oral MMF in the induction treatment of less
severe LN.
Kidney International (2016) 89, 235242; http://dx.doi.org/10.1038/
ki.2015.318
KEYWORDS: cyclophosphamide; lupus nephritis; mycophenolate mofetil
2015 International Society of Nephrology

Correspondence: Manish Rathi, Department of Nephrology, Post Graduate

Institute of Medical Education and Research, Sector-12, Chandigarh 160 012,
India. E-mail: drmanishrathi2000@yahoo.co.in
Received 22 May 2015; revised 4 August 2015; accepted 20 August
2015; published online 21 October 2015
Kidney International (2016) 89, 235242

upus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE) and needs to be
treated with toxic immunosuppressive therapy.13 Attempts have been made to reduce toxicity by altering the
route of administration or dosage of drugs or substituting
them with less toxic alternatives.
Cyclophosphamide (CYC), the traditional standard treatment of LN,47 carries signicant dose-dependent short- and
long-term toxicity, prompting investigators to explore the
effectiveness of lower doses.8,9 The Eurolupus nephritis trial
(ELNT) demonstrated a comparable efcacy and safety prole
of low-dose CYC to the high-dose National Institutes of Health
(NIH) regimen.10 Mycophenolate mofetil (MMF), a selective
lymphocyte antiproliferative agent, has also emerged as a
promising drug for treatment of LN. Recent studies have
established MMF as a safe and an effective alternative to fulldose CYC for LN.1116 Both the ELNT regimen and MMF
have been used successfully in subjects with less severe LN with
the advantage of reduced toxicity. However, it is not clear
whether low-dose ELNT CYC or oral MMF is superior, because
these have not been compared in a head-to-head trial. The
present study was aimed at comparing the efcacy and safety of
these treatment options in subjects with less severe LN.
RESULTS

A total of 173 subjects fullling the inclusion criteria were

screened during the study period. Of these, 100 were randomized to receive either low-dose intravenous CYC (n 50)
or oral MMF (n 50). The reasons for exclusion of 73
subjects are summarized in Figure 1.
The baseline characteristics of the study population are
described in Table 1. There were 8 males and 92 females in the
cohort. All the baseline characteristics were comparable between the two groups, with the exception of urine protein/
creatinine ratio (uPCR), which was signicantly higher in the
CYC group (3 vs. 2.2 in the MMF group, P 0.02). The
clinical presentation, organ involvement, and the distribution
of various biopsy classes were also similar in the two groups
(Table 1).
Of the 50 subjects in CYC group, 40 (80%) received the
target cumulative dose of 3 g, whereas 48 (96%) subjects in
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis

Screened (n = 173)
Biopsy diagnosis of lupus nephritis class
III/IV/V

Reasons for exclusion (n = 73)

Crescentic LN (n = 24)
Serum creatinine > 265.0 mol/l (n = 16)
Previously received CYC or MMF (n = 21)
Refused consent (n = 5)
Pregnant (n = 1)
CNS or pulmonary lupus (n = 6)

Randomized (n = 100)

50: Low fixed dose

intravenous CYC

50: Oral MMF

Withdrawn (n = 9)

Withdrawn (n = 8)

Death (n = 2)
Adverse events (n = 3)
Lost to follow-up (n = 3)
Deviated from protocol (n = 2)

Death (n = 5)
Adverse events (n = 1)
Lost to follow-up (n = 2)

Completed 24 weeks of follow-up

(n = 41)

Completed 24 weeks of follow-up

(n = 42)

Figure 1 | Flowchart depicting patient enrollment and follow-up. CNS, central nervous system; CYC, cyclophosphamide; LN, lupus nephritis;
MMF, mycophenolate mofetil.

the MMF group received the target dose of 1.53.0 g/day with
a mean dose of 2.22  0.39 g/day.
Study outcomes

The primary, as well as the secondary outcome measures were

assessed at 12 and 24 weeks according to the original assigned
groups (intention-to-treat (ITT) analysis), as well as the
completed follow-up groups (as-per-protocol [APP] analysis).
The rates of treatment response and complete renal remission
at these time points as per the two analyses are summarized in
Table 2.
The serum creatinine, serum albumin, uPCR, and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)
score improved signicantly in both the groups over the
study period, and there were no differences between the
treatment groups (Figure 2). The median (interquartile
range) SLEDAI score at the end of 24 weeks was 6 (4, 8) and
4 (2, 6) in the CYC and the MMF group, respectively
236

(P 0.17). The delta estimated glomerular ltration rate

improved by 14.0 ml/min (95% condence interval: 4.3, 23.7)
in the CYC group (P 0.005) and 16.5 ml/min (95% condence interval: 4.9, 28.0) in the MMF group (P 0.006)
over 24 weeks, with no signicant intergroup difference
(P 0.74). The anti-doublestranded deoxyribonuclease
antibody positivity rate declined from 90 to 58% in the CYC
group (P < 0.001) and 88 to 62% in the MMF group
(P 0.01) over 24 weeks, with no signicant intergroup
difference (P 0.84). The prevalence of hypocomplementemia (low C3 or C4) declined from 92 to 32% in
the CYC group (P < 0.001) and from 76 to 40% in the MMF
group (P < 0.001), without any signicant difference between
the two treatment groups (P 0.53).
The response rate for different pathological classes of LN
according to the treatment group was also analyzed. Using
ITT analysis, the treatment response rate in class IV was
76.7% in the CYC group compared with 70.4% in the MMF
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis

Table 1 | Baseline characteristics of the study population

CYC

MMF

Variable

n [ 50

n [ 50

P-value

Gender, n (%)
Female
Male

45 (90)
5 (10)

47 (94)
3 (6)

0.715

Kidney biopsy class, n (%)

III/IIIV
IV/IVV
V
Age (years)
Body mass index (kg/m2)
SLEDAI scorea
Anti-dsDNA positive, n (%)
Hypocomplementemia
(Y C3 or C4), n (%)
Hemoglobin (g/l)
Leukocyte count (x109/l)b
Platelet count (x109/l)b
Blood urea nitrogen (mmol/l)b
Serum creatinine (mmol/l)b
Urine protein/creatinine ratiob
eGFR (ml/min)c
Serum albumin (g/l)

6 (12)
30 (60)
14 (28)
30.6  9.5
22.3  3.1
18.1  6.2
45 (90)
46 (92)

11
27
12
28.3
22.5
17.9
44
38

89  18
6.5 (4, 8)
143.5 (108, 264.8)
6.7 (5.5, 10)
77.3 (70.7, 123.8)
3.0 (1.9, 4.4)
75.8  31.2
24.7  7.0

(22)
(54)
(24)
 9.5
 3.6
 5.6
(88)
(76)

0.414

0.237
0.85
0.866
1
0.056

94.4  24
6.8 (4.8, 9.1)
220 (133.8, 269)
6.0 (4.5, 8.5)
79.6 (70.7, 123.8)
2.2 (1.6, 3.4)
78.3  32.9
27.4  8.0

0.203
0.311
0.177
0.178
0.942
0.024
0.693
0.082

CYC, cyclophosphamide; dsDNA, double-stranded DNA; eGFR; estimated glomerular ltration rate; MMF, mycophenolate mofetil; SLEDAI, Systemic Lupus Erythematosus
Disease Activity Index. Value in bold is statistically signicant.
a
Scoring done according to the Safety of Exogenous Estrogens in Lupus Erythematosus National Assessment (SELENA) modication.
b
Measure of central tendency values indicated as median (interquartile range), others as mean  SD.
c
eGFR calculated using the Modied MDRD (Modication of Diet in Renal Disease) equation.

group (P 0.59); in class III it was 66.7% in the CYC group

compared with 90.9% in the MMF group (P 0.21), whereas
in class V it was 71.4% in the CYC group compared with
66.7% in the MMF group (P 0.79). The treatment response
rate did not differ signicantly in the two treatment groups
even after the exclusion of subjects with pure class-V LN (75.0
and 76.3% in CYC and MMF groups, respectively, P 0.91).
The median time to response was 10 (4, 20) weeks in the
CYC group as compared with 12 (6.5, 12) weeks in the MMF
group (P 0.90). Similarly, there was no difference in the
median time to complete remission in the two groups (9 (7.5,
21) weeks and 12 (8, 20) weeks in the CYC and MMF group,
respectively; P 0.88). The probability of response, as well as
remission was also not different between the treatment groups
Figure 3).

summarized in Table 3. Both the groups had an equal number

of infection episodes. However, more patients receiving MMF
experienced gastrointestinal (GI) symptoms (P < 0.001).
There was no difference in the incidence of infertility or
menstrual abnormalities between the two groups. Three
subjects in the CYC group and one subject in the MMF group
required discontinuation of treatment because of adverse
events.
There were ve deaths in the MMF group and two in the
CYC group (P 0.43). Of the ve deaths in the MMF group,
two were due to severe neuropsychiatric lupus, one due to
lupus enteritis and septic shock, whereas the cause was not
clear in the other two cases. The cause of death in two subjects in the CYC group was unknown.
Economics of the therapy

Adverse events

During the study period, 25 (50%) subjects in the CYC group

and 32 (64%) subjects in the MMF group reported at least
one adverse event (P 0.32). The reported adverse events are

The cost of monthly therapy with MMF was fourfold higher

than the CYC therapy (8500 vs. 2200 INR or 100 vs. 20
Euros). Over a period of 6 months, the cumulative cost of
MMF therapy was almost seven times that of 3-month CYC

Table 2 | Outcome variables in the 2 groups as per the ITT and APP analysis
ITT
Outcome measures
Response-12 weeks
Remission-12 weeks
Response-24 weeks
Remission-24 weeks

APP

CYC (n [ 50) MMF (n [ 50) Odds ratio (95% CI) P-value

31
16
37
25

(62%)
(32%)
(74%)
(50%)

29
21
37
27

(58%)
(42%)
(74%)
(54%)

0.85
1.54
1.0
1.17

(0.352.03)
(0.633.79)
(0.372.70)
(0.502.77)

0.84
0.41
1.0
0.84

CYC
26/41
13/41
33/41
20/41

(63.4%)
(31.7%)
(80.5%)
(49.0%)

MMF
29/44
17/44
34/42
25/42

(65.9%)
(38.6%)
(80.9%)
(59.5%)

Odds ratio (95% CI) P-value

1.12
1.36
0.93
1.47

(0.422.98)
(0.513.67)
(0.253.22)
(0.563.86)

0.99
0.65
1.0
0.52

APP, as-per-protocol; CI, condence interval; CYC, cyclophosphamide; ITT, intention-to-treat; MMF, mycophenolate mofetil.
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40
MMF
CYC

95

Serum albumin

Serum creatinine

105

90
85
80
75

MMF
CYC

35
30
25

12
Time

24

12
Time

24

3.5
CYC
MMF

15
SLEDAI

uPCR

CYC
MMF

2.5

10

1.5
5

0.5
0

12
Time (weeks)

24

12
Time (weeks)

24

Figure 2 | Changes in serum creatinine, serum albumin, uPCR, and disease activity (SLEDAI) score over the 24-week induction period.
Within each treatment group, the biochemical parameters and uPCR all showed signicant improvement over time (P < 0.05). Comparisons of
each variable between treatment groups showed no signicant differences (P > 0.05). CYC, cyclophosphamide; MMF, mycophenolate mofetil;
SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; uPCR, urine protein/creatinine ratio.

and 3 months of azathioprine therapy (52,000 INR [618 Euros]

vs. 7700 INR [90 Euros]).
DISCUSSION

In this randomized trial, we compared low-dose intravenous

CYC with oral MMF in the induction treatment of mild to
moderately severe LN. We observed that the treatment
response and complete remission rates, as well as adverse
event rates were comparable in the two groups.
Many observational and randomized trials were conducted to identify the most effective and safe therapy for
patients with LN. Studies have shown that both the low-dose
intravenous CYC and oral MMF are equally efcacious and

safe alternatives compared with the conventional NIH

regimen of high-dose intravenous CYC. The ELNT trial had
compared six fortnightly injections of CYC at a xed dose of
500 mg with high-dose monthly injections.10 Follow-up for
up to 10 years showed that there were no differences in the
outcomes parameters or the side effects between high- and
low-dose intravenous CYC.17 Similarly, the Aspreva Lupus
Management Study (ALMS) trial had compared oral MMF
with monthly high-dose intravenous CYC and noted equal
rates of complete and partial remission in the two treatment
groups.15 However, to date there have been no studies
directly comparing the low-dose CYC regimen with oral
MMF.

Survival for response

Survival for remission

1.0

1.0

CYC
MMF

0.6
0.4

0.8
Survival probability

Survival probability

0.8

0.6
0.4

0.2

0.2

0.0

0.0
0

10
15
Time

20

CYC
MMF

10
15
Time

20

Figure 3 | Kaplan-Meier analysis of probability of response (P [ 0.833) and probability of remission (P [ 0.921) in the 2 treatment
groups. CYC, cyclophosphamide; MMF, mycophenolate mofetil.
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis

Table 3 | Adverse events during 24-week induction phase

Adverse events

CYC
n [ 50

MMF
n [ 50

Death
Patients with at least one AE

2 (4.0)
25 (50)

5 (10)
32 (64)

Infections (total)
Pneumonia
Urinary tract infection
Esophageal candidiasis
Breast abscess
Gluteal abscess
Herpes zoster
Pulmonary tuberculosis
Acute parotitis
Shock

13
4
3
0
0
1
5
0
0
1

10
4
1
1
1
0
3
1
1
1

GI symptoms
Gastric ulcer
Transaminitis
Cytopenia
Leg ulcers
Steroid induced diabetes
Deep vein thrombosis

2 (4.0)
1
0
5
3
1
2

26 (52)*
0
1
7
0
2
1

0
3
0
1
1
1
1
1
0

1
1
1
0
1
0
2
0
1

Neurological
Headache
Seizures
Stroke
Psychosis
Worsened GFR
Menorrhagia
Amenorrhea
Alopecia
Diffuse alveolar hemorrhage

AE, adverse event; CYC, cyclophosphamide; GFR, glomerular ltration rate; GI,
gastrointestinal; MMF, mycophenolate mofetil.
The bold and asterisk mark indicate signicant difference in the 2 groups.
*P < 0.001.

At the end of 24 weeks, we noted similar treatment

response of 74% in both the groups, whereas complete renal
remission was achieved in 50% in the CYC group and 54% in
the MMF group. Chan et al.11 compared MMF with oral CYC
for LN induction in Chinese subjects and noted a comparable
complete remission in each treatment arm (81% in the MMF
group vs. 76% in the CYC group). These remission rates were
higher as compared with those seen in our study. This may be
in part due to the fact that the results in the Chinese study
were analyzed at the end of 12 months in contrast to
6 months in our study. Achievement of remission is cumulative over a period of time after completion of the induction
phase.18 On the other hand, the response and remission rates
achieved in our study are better than those seen in the ALMS
trial, which showed response rates of 56.2% and 53.0% and
complete remission rates of 8.6% and 8.1% in the MMF and
high-dose intravenous CYC groups, respectively.15 This difference may be due to various reasons. In contrast to the
ALMS trial, the present study excluded subjects with estimated glomerular ltration rate of <30 ml/min. Second, the
percentage of subjects with different biopsy classes in the two
studies is different, with more subjects with pure class-V LN
in our study. Finally, the racial background of subjects in the
two studies is different. The ALMS trial included subjects with
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different racial backgrounds, and 12.5% were Black, whereas

in our study all subjects were Asians. The rate of remission in
the CYC arm of our study is also better than that reported in
the multicenter study by Ginzler et al.13, which showed
signicantly higher rates of complete remission with MMF
compared with high-dose intravenous CYC (22.5 vs. 5.8%,
P 0.005).
The high response rate with MMF in our study occurred
despite a lower received MMF dose. Only 40% subjects were
able to achieve to receive the target 2.53.0 g dose. This is less
than that achieved by Ginzler et al. (63%),13 or the ALMS trial
(91.3%).15 The mean dosage of MMF in our study population
(2.22  0.39 g/day) was also less than that in the other two
trials (2.68 and 2.47  0.58 g/day, respectively).13,15
Compared with the ELNT trial,10 the dose of steroid used
in our treatment protocol was high, and it is possible that
steroids may have driven a signicant part of the benecial
effects of the induction therapy at week 24. However, the
steroid dose used in our study was close to the one used in the
ALMS trial,15 where a dose of 0.751 mg/kg per day was used
for an unspecied period followed by taper to 10 mg/day.
As compared with low-dose CYC, there were more adverse
events in the MMF group; however, the differences were not
signicant. The commonest adverse event was GI intolerance
and infections. GI symptoms were more frequent in the MMF
group. Although the GI manifestations are known complications of MMF therapy,19,20 no previous studies have reported
any difference in GI symptoms between MMF and CYC
groups.1113,15 In our study, the dose of CYC was less as
compared with previous studies, and majority of GI symptoms
like nausea and vomiting with CYC are dose related. The
ELNT trial did not provide details regarding GI side effects in
the low-dose CYC group,10 but no one withdrew from the
study for GI toxicity. Another possible reason could be a direct
increase in the dose of MMF from 1000 mg bid to 1500 mg bid
without a stepwise increase (e.g., 2500 mg in divided doses);
however, we did not notice any particular trend of increased GI
upset during the hike to this dose at 4-week duration.
The number of infection episodes was similar in both
groups in this investigation. Earlier studies that have
compared MMF with either oral or high-dose intravenous
CYC have also found similar rates of infections.1115 The rate
and severity of infections were similar in the two groups on
CYC in the ELNT trial.10 The menstrual abnormalities were
also not different in the two groups in our study. The side
effect rate of alopecia in our study was lower in both the
treatment groups as compared with the ALMS trial (11% in
MMF and 36% in CYC).15 Although the exact reasons for this
difference are unclear, it may be due to lower doses of the
drugs used in our study as compared with ALMS. Genetic
differences in the drug metabolism and cultural differences in
the concern about body image when faced with a potentially
serious illness may also be responsible for this difference.
The mortality rate in our study was 10% in the MMF group
and 4% in the CYC group, compared with 4.9 and 2.8%,
respectively, in the ALMS study.15 Close follow-up, regular dose
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis

adjustments, and a timely switch to monthly CYC regimen in

cases of non-responsive patients may help in reducing the
mortality rate. Similarly, understanding how MMF blood levels
correlate with response and toxicity may also permit more
careful monitoring of the drug and decrease adverse outcomes.
Although we observed no difference in the treatment
outcomes in the MMF and CYC groups, low-dose intravenous CYC appeared to have some advantages over MMF.
These include a better GI tolerability and shorter course of
induction treatment. The CYC was given in the day care
setting, avoiding hospitalization and ensuring that the drug
was received. The total treatment cost over a 6-month period
was almost sevenfold lower in the CYC group as compared
with the MMF group. Ours is a public sector hospital that
does not charge patients for infusion, nursing, or day care
treatment, and this cost difference was despite using generic
MMF. The cost of therapy is a major factor driving treatment
decisions in economically deprived countries. Considering
these advantages, it is reasonable to choose low-dose CYC
over MMF for the treatment of less severe LN, particularly
when the cost of therapy is met by out-of-pocket expenditure.
However, it is worth pointing out that the cost difference is
related to the way the health-care system is structured, and
the cost advantage of CYC therapy may be lost if payment is
needed for extra visits, infusion, or nursing care.
These results should be interpreted in the light of several
limitations of our study. This was a single-center study with
subjects belonging to a single ethnicity. Thus, the results need
validation in a large multicenter study involving different
races and ethnicities. Moreover, 25% patients in our study
had pure class-V lesion, which is considered to be a more
benign disease, and results may have been different had we
included only proliferative LN. Another important limitation
is that the dose of MMF was not concentration controlled.
There may be some differences in the metabolism of this drug
by race leading to higher exposure and toxicity in our subjects
despite receiving a relatively low dose. Our study also had a
short follow-up; thus, we cannot predict the durability of
response over the long term. The study was not blinded, and
this might have led to biases in recruitment of subjects or
analysis of results. Finally, patients with severe LN and crescentic LN were excluded by design, and thus it remains to be
seen how each of these treatment regimens performs in that
situation.
In conclusion, our study demonstrates low-dose intravenous CYC to be as effective as oral MMF, with fewer GI side
effects, and thus is a good induction treatment option for
patients with moderately severe LN in the Indian population.
Larger multicenter studies with a longer follow-up are
required to extrapolate these results to lupus populations in
other parts of the world.
MATERIALS AND METHODS
Study design and subjects
This was an open-label, prospective, randomized, non-inferiority,
parallel group study conducted at a single center with the
240

hypothesis that the low-dose intravenous CYC is similar to oral

MMF in terms of efcacy and safety in subjects with less severe LN.
Subjects were enrolled from the Nephrology and Rheumatology
departments of the Post Graduate Institute of Medical Education and
Research, Chandigarh, between June 2011 and March 2014. Patients
of either sex between the ages of 12 and 65, diagnosed to have SLE as
per American College of Rheumatology (ACR) criteria,21 and
biopsy-proven class III, IV, V, IIIV, or IVV LN based on the
International Society of Nephrology/Renal Pathology Society classication were included.22 Those with crescentic LN (>50% crescents
in biopsy), serum creatinine of >265.0 mmol/l, neurological or
pulmonary lupus, ongoing infection, pregnancy, and prior treatment
with CYC or MMF were excluded. The study was approved by the
Institute Ethics Committee and was registered with Clinical Trial
RegistryIndia (CTRI/2013/12/004179). An informed consent was
obtained from all study participants or their parents/legal guardians,
and the procedures followed were in accordance with the ethical
standards of the responsible committees on human experimentation
(institutional and national) and with the Declaration of Helsinki
Principles 1975, as revised in 2000.
Study treatment and drug dosing
MMF was initiated at a dose of 500 mg twice a day and increased
every 2 weeks to achieve a target dose of 1.53.0 g/day, depending on
the leukocyte count and tolerability. At 2 weeks, the dose was
increased to 1000 mg twice a day, whereas it was increased to a
maximum dose of 1500 mg twice a day at 4 weeks. In case of GI
intolerance, the frequency of drug was changed to thrice daily, followed by a change to mycophenolate sodium formulation if
required. In case of persistence of symptoms, the dose of MMF was
reduced stepwise by 25%. CYC was administered as six fortnightly
intravenous infusions at a xed dose of 500 mg each. In addition, all
subjects received three daily intravenous injections of methylprednisolone (750 mg each) at the beginning of treatment followed by
oral prednisolone (1 mg/kg per day) for 8 weeks and subsequent
tapering. All subjects were given hydroxychloroquine (6 mg/kg,
single daily dose) as well as either angiotensin-converting enzyme
inhibitors or angiotensin receptor blockers. At the end of induction
treatment, that is, 6 months in the MMF group and 3 months in the
CYC group, all subjects were shifted to maintenance treatment with
azathioprine (2 mg/kg) and steroids (57.5 mg/day). The treatment
protocol remained the same with no change during the trial period.
Follow-up visits
Subjects in the CYC group were followed-up every 2 weeks for
12 weeks and then every 4 weeks through week 24. Those in the
MMF group were followed-up at week 2, week 4, and subsequently
every 4 weeks through week 24. A monthly telephonic contact was
made throughout the study period to collect safety and concomitant
medication information.
Baseline investigations included complete blood counts, renal
function tests, serum albumin, urine examination, uPCR in a 24 h
urine sample, anti-nuclear antibodies, anti-doublestranded deoxyribonuclease antibody, and complement levels. At each follow-up,
complete blood counts, renal function tests, and uPCR were performed, whereas complement levels and anti-doublestranded
deoxyribonuclease antibody were checked at the end of 12 and
24 weeks. The disease activity was assessed by SLEDAI scoring according to Safety of Exogenous Estrogens in Lupus Erythematosus
National Assessment modication (SELENASLEDAI) at baseline,
12 weeks, and 24 weeks.23,24 The estimated glomerular ltration rate
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M Rathi et al.: Low-dose intravenous CYC versus oral MMF in lupus nephritis

was calculated using modied Modication of Diet in Renal Disease

(MDRD) equation at baseline, 12 weeks, and 24 weeks.25
Study end points
The primary outcome measure was treatment response, dened as a
decrease in the uPCR to <3 in subjects with a baseline ratio $3 or a
decrease in uPCR by $50% in those with a baseline ratio <3, along
with stabilization or improvement in serum creatinine (a 24-week
serum creatinine level within 25% of baseline). The secondary
outcome measures were as follows: (i) complete renal remission,
dened as return to normal serum creatinine along with
proteinuria #0.5 g/day and inactive urine sediment, (ii) SELENA
SLEDAI score, and (iii) adverse events.
The sample size was determined using the Sealed Envelope
sample size calculator to determine the sample size for a 2 arm,
randomized, parallel group trial with the outcome variable being
binary and the objective of showing non-inferiority. Assuming a
response rate of 56% with MMF (as per the ALMS trial),15 and 71%
with low-dose CYC (as per the ELNT study)10 and the noninferiority criteria of 10%, it was estimated that to achieve 80%
power with one-sided condence interval of 95%, 45 subjects per
group would be required, thus giving a sample size of 90. Further,
accounting for a withdrawal rate of 10%, 50 subjects per group
needed to be recruited, leading to a total sample size of 100 subjects.
The randomization was performed with an in-center computergenerated random number table by an authorized study coordinator,
and the subjects were randomized in a 1:1 ratio to receive either
intravenous low-dose CYC or oral MMF.
Statistical analysis
Analyses were performed by considering all observations pertaining
to each variable. Hence, the data set was not adjusted by omitting all
missing variables globally. The results under APP analysis thus have
different sample sizes (n), depending on the missing observations
therein. Missing observations were imputed under a multivariate
setting, where other variables were taken as predictors for imputing
missing observations of the individual variables for ITT analysis.
Continuous data are presented as mean  SD or median and
interquartile range, as appropriate. Normality of the quantitative
data was checked by the Kolmogorov-Smirnov test. For normally
distributed data, means for the two groups were compared using
Students t-test, whereas non-normal data were tested by the MannWhitneys U-test. With in-patientrelated variables were compared
using a paired t-test or analysis of variance. Change in the SLEDAI
score was assessed by the Wilcoxon signed-rank test. Qualitative or
categorical variables were described as frequencies and proportions.
Proportions were compared using c2 or Fisher exact test as applicable. The McNemar test was applied to compare between pre- and
post-treatment values. A two-sided P-value of <0.05 was considered
signicant. All calculations were performed using SPSS version 21
(Statistical Packages for the Social Sciences, Chicago, IL) on a
Windows platform.
DISCLOSURE

All the authors declared no competing interests.

ACKNOWLEDGMENTS

We thank Dr Brad H Rovin (Professor and Director, Division of

Nephrology, Department of Internal Medicine, The Ohio State
University, OH, USA) for reviewing the manuscript. He has performed
language editing and provided valuable feedback to improve the
quality of paper.
Kidney International (2016) 89, 235242

clinical trial

AUTHOR CONTRIBUTIONS

All the authors meet the four criteria dened by ICMJE. They have
made substantial contributions to the conception or design of the
work or the acquisition, analysis, or interpretation of data for the
work. The authors have contributed to the draft preparation and
revising it critically for important intellectual content. All the authors
have approved the nal version of the draft and agree to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved. In addition, MR has
conceptualized and designed the study; AG and AJ have recruited the
patients and randomized them; MR, AG, and PKG have performed the
data acquisition and statistical analysis; MR and AS have supervised
the randomization and patient recruitment and contributed to
patient management and end point assessment; MR, AG, and AJ have
drafted the manuscript; RR, AS, and VK have helped in data
acquisition, data analysis, and literature search; VJ and HSK have
supervised the patient management, edited the manuscript, and
provided intellectual support; and KLG and VS have supervised the
study, provided intellectual support, critically reviewed, and edited
the manuscript.
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