Tacrolimus or mycophenolate for lupus nephritis: a trade in side effects

The edition in brief

The edition closes on a 96-week Asian multicentre trial in 130 people with class III/IV, with or without class V, lupus nephritis. Tacrolimus with glucocorticoids gave sustained renal response in 58.5% against 69.2% with mycophenolate, a difference that was not statistically significant, and complete remission in 55% versus 63%. Safety differed: acute kidney injury and tremor were more common with tacrolimus, while leucopenia, serious infections and all three deaths occurred with mycophenolate. Tacrolimus is a reasonable choice when infection or leucopenia is the main worry, but the numerical efficacy gap means mycophenolate remains the default. In a post hoc analysis of a 116-patient haemodialysis trial, potassium-guided sodium zirconium cyclosilicate on non-dialysis days tripled the chance of sustained potassium control, with fewer hyperkalaemic readings; clinical outcomes were not assessed. Across three US health systems, a family history of kidney disease was recorded for only 5.4% of 1.1 million adults, yet was associated with three times the odds of kidney failure. A meta-analysis found the Thakar score best predicted AKI needing dialysis after cardiac surgery (AUC 0.80). The pearl covers emergency hyperkalaemia.