The edition · Nephrology
Tacrolimus against mycophenolate in lupus nephritis over two years, and the itch that affects most dialysis patients
An Asian randomised trial of 130 patients found no significant difference in sustained renal response, but different harms: more kidney injury and tremor with tacrolimus, more serious infections with mycophenolate. Pruritus affected 60% of haemodialysis patients, most consistently linked to phosphate.
The edition in brief
A multicentre Asian trial randomised 130 patients with biopsy-proven class III/IV (with or without V) lupus nephritis to tacrolimus or mycophenolate, each with glucocorticoids, as continuous induction and maintenance for 96 weeks. Sustained renal response was 58.5% v 69.2% and complete remission 55.4% v 63.1%, neither significantly different; overall adverse events were identical at 80%, but tacrolimus caused more acute kidney injury and tremor, while mycophenolate caused more leucopenia, more treatment-related serious adverse events and serious infections, and all three deaths. The trial was not designed to show equivalence. A meta-analysis of 25 studies (8,955 patients) put pruritus prevalence in maintenance haemodialysis at 60%, with raised phosphate (OR about 2–3) and diabetes associated with itch, and high-flux dialysis with less. Across three US health systems covering 1.1 million adults, a family history of kidney disease was recorded in only 5.4% of records, yet was associated with CKD (OR 1.39) and kidney failure (OR 3.15). A meta-analysis of seven studies found no overall fall in eGFR after ureteroscopy in patients with CKD, on very low-certainty evidence. The pearl covers phosphate binders and hidden dietary phosphate. There was no FDA activity for this desk today.
Six in ten haemodialysis patients itch, and phosphate was the most consistent link
Screen haemodialysis patients for itch and check phosphate and dialysis adequacy first.
Family history of kidney disease is rarely recorded but tracked with kidney failure
Add a kidney disease question to every family history and test those with an affected relative.
Ureteroscopy did not reduce eGFR overall in patients with CKD
CKD alone need not deter endoscopic stone treatment; monitor renal function around the procedure.
Phosphate binders work with food, and much dietary phosphate is hidden
Check that binders are taken with every meal and target hidden phosphate additives in the diet.
Tacrolimus versus mycophenolate in lupus nephritis: similar response, different harms
Tacrolimus is a reasonable alternative to mycophenolate in lupus nephritis for selected patients, chosen on its harm profile.
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