Comparable 12-month renal response outcomes with medium- vs high-dose starting prednisone in a real-world study of Lupus Nephritis

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OBJECTIVE: The optimal starting dose and tapering of glucocorticoids (GC) in LN remains unknown. We aimed to assess whether a higher prednisone dose results in better 12-month complete renal response (CRR) rates compared with a lower dose, in a contemporary multicentre cohort of LN patients. METHODS: Retrospective and prospective cohort study of patients with new-onset biopsy-proven LN (period 2014-to date). Overall and complete renal response rates at 12 months were compared between patients who started with high (>40 mg/day) vs low-medium (≤40 mg/day) prednisone dose. Multivariable regression and time-to-response analyses were performed, applying inverse probability of treatment weighting (IPTW) to balance baseline covariates and minimize confounding. RESULTS: A total of 162 patients were included; 101 received a low-medium starting prednisone dose (median 30 mg/day) and 61 received a high dose (median 60 mg/day). Cumulative prednisone exposure in the first year was significantly higher in the high-dose group (6.9 g vs 4.0 g; P < 0.001), although cumulative doses equalized by years 2 and 3. The 12-month CRR rates were comparable between the high- and medium-dose groups (65.4% in the low-medium vs 71.2% in the high-dose group, P = 0.55). In multivariable logistic regression with IPTW, a higher initial prednisone dose was not associated with better CRR rate (adjusted OR 1.00; 95% CI: 0.46-2.22). Similarly, time-to-response analyses showed no difference in achieving overall renal response (log-rank P = 0.26). CONCLUSION: Despite significantly increasing GC exposure, a higher starting prednisone dose was not associated with improved renal response rates at 12 months in a contemporary LN cohort.

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