IV methylprednisolone pulse no better than oral steroids alone for tubulointerstitial nephritis

A new study published in Nephrology Dialysis Transplantation suggests that in individuals with tubulointerstitial nephritis brought on by sarcoidosis, intravenous methylprednisolone pulse (MP) may not provide any further benefits for renal function above conventional oral steroid therapy.

An organ may become dysfunctional as a result of the multinucleated giant cell granulomatous lesions and noncaseating epithelioid cells that define the chronic systemic inflammatory condition known as sarcoidosis. Here, Matthieu Mahevas and colleagues present the findings of a multicenter, randomized, open-label trial that compared the effectiveness and safety of oral prednisone combined with an initial pulse of methylprednisolone (the MP group) versus prednisone taken orally alone (the PRD group) in patients with biopsy-confirmed TIN due to sarcoidosis.

At 21 sites in France, this prospective, open-label, randomized, controlled trial involved patients with biopsy-confirmed acute tubulointerstitial nephritis due to sarcoidosis. Patients were given either a 15 mg/kg/day methylprednisolone pulse followed by 3 days of oral prednisone (MP group) or just 1 mg/kg/day of oral prednisone alone (PRD group) at random. A favorable response was measured as a doubling of estimated glomerular filtration rate (eGFR) after three months as compared to the eGFR before.

The key findings of this study were:

1. For this study, 40 participants were randomly assigned. Prior to PRD, baseline eGFR was 22 mL/min/1.73 m2, and prior to MP, it was 25 mL/min/1.73 m2.

2. The mean percentage of interstitial fibrosis and the degree of the interstitial infiltration in the two groups did not differ.

3. The median eGFR at 3 months in the population being treated, consisting of the PRD and MP groups, was 45 and 46 mL/min/1.73m2, respectively.

4. 16 of 20 PRD patients and 10 of 20 MP patients met the primary end point at 3 months. After 1, 3, 6, and 12 months of treatment, there was little difference in the eGFR between the two groups.

5. The eGFR at 1 month and the eGFR at 12 months for both groups showed a significant correlation.

6. The severity of the adverse events was the same for the two groups.

Over a conventional oral corticosteroid regimen, this tactic did not provide any additional benefits for kidney health. The pathophysiological mechanisms underlying renal lesions should be better understood to produce more targeted and efficient treatments.

Reference:

Mahevas, M., Audard, V., Rousseau, A., Cez, A., Guerrot, D., Verhelst, D., Delahousse, M., Hanrotel, C., Pillebout, E., Daugas, E., Krastinova, E., Valeyre, D., Jean-Marc, N., … Sandrine, H. (2022). Efficacy and safety of methylprednisolone pulse followed by oral prednisone vs. oral prednisone alone in sarcoidosis tubulointerstitial nephritis: a randomized, open-label, controlled clinical trial. In Nephrology Dialysis Transplantation (Vol. 38, Issue 4, pp. 961–968). Oxford University Press (OUP). https://doi.org/10.1093/ndt/gfac227