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  Most popular articles (Since June 29, 2016)

 
 
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TOPICAL REVIEW
New treatments for systemic lupus erythematosus
Robert George Lahita
March 2017, 12(1):48-51
DOI:10.4103/injr.injr_1_17  
New therapies for systemic lupus erythematosus are rare. This is because of the complexity of the disease and its varied presentations. There are many variables and a variety of measurement scales that must be satisfied before a new agent is approved for use in humans. Attempts are ongoing to develop biological treatments for the disease using three approaches: B cell modulation, T cell regulation and cytokine inhibition. This paper reviews the current state of these three critical areas.
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ABSTRACTS
IRACON 2016: Poster Presentations

October 2016, 11(5):20-108
  4,327 481 -
Poster Presentations

November 2017, 12(5):16-132
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REVIEW ARTICLES
Neonatal lupus: An update
Sathish Kumar
November 2016, 11(6):139-144
DOI:10.4103/0973-3698.194548  
Neonatal lupus erythematosus (NLE) is a syndrome that usually presents in the fetus or neonates that is caused by transplacental passage of autoantibodies from the mother. It is a clinical spectrum of cutaneous, cardiac, and systemic abnormalities observed in the newborn or infants whose mothers have autoantibodies against Ro/SSA and/or La/SSB. Congenital complete heart block is the most serious manifestation of NLE that can develop in utero or after birth. Multidisciplinary team involvement is indicated. This article will provide an overview the presentation of NLE and will review the evidence for current therapies.
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REVIEW
Pulmonary hypertension associated with connective tissue disease
Srinivas Rajagopala, Molly Mary Thabah
March 2017, 12(1):38-47
DOI:10.4103/0973-3698.199124  
Pulmonary hypertension (PH) is an important cause of morbidity and mortality in connective tissue diseases (CTDs). CTDs may cause PH due to several mechanisms; pulmonary arterial hypertension, associated interstitial lung disease, neuromuscular disease, and/or sleep disordered breathing leading to hypoxia, associated thromboembolic PH, and pulmonary venous hypertension due to left ventricular dysfunction. PH can be measured on echocardiography, but the gold standard for diagnosis is right heart catheterization. PH-specific therapy in addition to immunosuppression is the most common treatment used though data are scant. In this narrative review, we discuss the epidemiologic burden, clinical presentation, evaluation, and management of PH in CTDs.
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LETTERS TO EDITOR
Splitting dose of methotrexate in the management of rheumatoid arthritis: Making a mountain out of a molehill?
Navaf Kozhippurath Mohamedali, Vinod Ravindran
June 2017, 12(2):114-115
DOI:10.4103/injr.injr_42_17  
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REVIEW ARTICLES
Paradigm shift in clinical trial regulations in India
Sandeep Lahiry, Rajasree Sinha, Shouvik Choudhury, Ayan Mukherjee, Suparna Chatterjee
March 2018, 13(1):51-55
DOI:10.4103/injr.injr_110_17  
India has the potential to contribute meaningfully to global clinical drug development. A critical enabler to achieve this potential is a balanced, predictable, and scientifically robust regulation involving clinical studies. In the past few years, the country's regulatory milieu has witnessed a positive transformation to favour ethical conduct of clinical trials, while appropriately supporting patient safety. Numerous amendments to existing policies governing the conduct of clinical studies are predicted to bring a paradigm shift in the overall regulatory scenario. In such view, it is important for us as academicians, to be abreast of such changes. We, therefore, discuss major regulatory highlights involving clinical research in India.
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EDITORIALS
Checklist prior to biologics: Indian perspective
Rajkiran Dudam, Narsimulu Gumdal
September 2016, 11(3):126-128
DOI:10.4103/0973-3698.187419  
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BRIEF REPORT
Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study
Sayali Khedekar, Apurv P Shimpi, Ashok Shyam, Parag Sancheti
June 2017, 12(2):94-96
DOI:10.4103/0973-3698.199130  
Background: Conventional physiotherapy treatment for patients with rheumatoid hand emphasizes on single-plane movements and strengthening exercises directed toward improvement of function and prevention of deformities. This may be nondirective and lacks creativity and hence may predispose to a high attrition from therapy. The current study aimed to evaluate the efficacy of art as a creative therapeutic procedure for enhancement of hand functions, self-perception, and quality of life in patients with rheumatoid arthritis (RA). Methods: A single-blinded, randomized controlled pilot study was conducted on 17 participants suffering from RA. The control group received conventional physiotherapy while the experimental group received art-based intervention with bimanual projects (viz., origami, paper quelling, clay modeling, and oil painting). Both groups received intervention for 45 min daily for 4 weeks. Pre- and post-interventional assessment was done using grip and pinch strength, Grip Ability Test (GAT), Jebsen–Taylor Hand Function Test (JHFT), Australian-Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcome Questionnaire (MHQ), and Health Assessment Questionnaire (HAQ). Results: There was an improvement in hand functions (grip strength [P = 0.042], two-point pinch strength [P = 0.039], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]), and quality of life (HAQ;P = 0.043) in art therapy patients which was similar to conventional therapy patients. Conclusion: Art is an equally effective therapeutic intervention to conventional therapy for the enhancement of hand functions, self-perception, and quality of life in patients with RA.
  2,277 223 1
REVIEW ARTICLE
Emerging evidence-based therapies for systemic sclerosis
Jasmin Raja, Christopher P Denton
September 2016, 11(3):153-163
DOI:10.4103/0973-3698.187423  
Systemic sclerosis (SSc) (scleroderma) is an uncommon multisystem connective tissue disease with high unmet need and mortality. There has been an improvement in overall outcome and survival over the past three decades, but it still has the highest mortality among any of the autoimmune rheumatic diseases. Progress in its management has come through more organized assessment and treatment together with the emergence of therapies that can target specific complications of the disease such as renal crisis and pulmonary arterial hypertension. In addition, there is a growing understanding of pathogenesis that allows more targeted approaches to therapy to be explored in clinical trials. In this review, several aspects of SSc management including the more targeted therapies including strategies to block specific pathways or mediators have been discussed.
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REVIEW ARTICLES
Antiphospholipid syndrome in pregnancy
Anisur Rahman
November 2016, 11(6):117-121
DOI:10.4103/0973-3698.194543  
Antiphospholipid syndrome (APS) is an autoimmune condition, in which antiphospholipid antibodies (aPL) cause clinical features including thrombosis, fetal loss, and preterm delivery. Studies in large numbers of patients with APS show that they suffer both early and late fetal loss as well as complications of pregnancy such as preeclampsia. The fetal loss in patients with APS is not caused primarily by thrombosis, but by a number of biological effects of aPL that affect implantation of the embryo. These factors are not yet understood fully but include effects on trophoblast cell viability and migration, inflammation at the fetal-maternal interface, and activation of complement. The established management of pregnancy in patients with known obstetric APS is to give daily low-dose oral aspirin plus daily subcutaneous heparin. This gives a live birth rate of over 70%. The trials that led to this form of management being adopted were small but overall do support the use of the heparin/aspirin combination over aspirin alone. There is no definite evidence supporting the use of heparin plus aspirin in patients who are aPL-positive, but who have never suffered any problems in pregnancy. However, patients taking long-term warfarin for thrombotic APS should have this changed to heparin during pregnancy.
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Inflammatory rheumatic diseases in the elderly
Vikramraj K Jain, Vir Singh Negi
December 2016, 11(4):207-215
DOI:10.4103/0973-3698.192684  
Rapid aging of world's population will translate into more elderly patients in the near future. Diagnosis of inflammatory rheumatic diseases in this age group is complicated by atypical clinical features compared to the younger onset group, nonspecific positivity of serological parameters, and confounding radiological signs. Management of these diseases also presents unique challenges in lieu of altered physiology of elderly, cognitive decline, presence of comorbidities, and altered immune system (inflammaging). Hence, this review attempts to synthesize the existing knowledge of the clinical, diagnostic, and therapeutic idiosyncrasies of inflammatory rheumatic diseases in this subgroup of population.
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Fertility and pregnancy in systemic lupus erythematosus
Alexis Jones, Ian Giles
November 2016, 11(6):128-134
DOI:10.4103/0973-3698.194546  
Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disease with a heterogeneous pattern of clinical and serological manifestations. The predilection for women, particularly of childbearing age, combined with improved survival has led to increasing numbers of women with lupus considering pregnancy. Management of pregnancy in SLE however, requires careful planning and close medical and obstetric monitoring to ensure optimal outcomes. This review, discusses possible causes of subfertility, issues regarding contraception and family planning as well as management of lupus during pregnancy and outcomes in pregnant women with SLE.
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ORIGINAL ARTICLES
Test–retest reliability and correlates of 6-minute walk test in patients with primary osteoarthritis of knees
Mahamed Ateef, Sivachidambaram Kulandaivelan, Shaziya Tahseen
December 2016, 11(4):192-196
DOI:10.4103/0973-3698.192668  
Background: In the assessment of primary osteoarthritis (OA) of knees several clinical tool including 6 minutes walk test (6 MWT) are used. The objective of this study was to to analyze the test-retest reliability of 6 MWT and its correlation with various parameters. Methods: Eighty patients (age, 56-79 years) with OA of knees met the inclusion criteria. Demographic and clinical characteristics including radiological severity of OA (by X-ray K/L grading) were recorded. Patients filled in the knee injury and osteoarthritis outcome score (KOOS) questionnaire. All patients performed 6 MWT twice with at least 48 h gap in-between. Results: Test–retest reliability of 6 MWT in primary OA knee patients was excellent with ICC 0.991 (95% confidence interval was 0.986–0.994). 6 MWT had a weak correlation with KOOS-symptom and KOOS-activities of daily living (rho = 0.397 and 0.364 respectively), a strong correlation with KOOS-pain and KOOS-sports (rho = 0.605 and 0.521 respectively), and a very strong correlation with KOOS-quality of life (rho = 0.758). It had a weak correlation with age and height (r = 0.497 and 0.302), a strong correlation with VAS, weight, and BMI (rho = −0.655, r = −0.510, and − 0.691, respectively), and a very strong correlation with disease severity (rho = −0. 849). Conclusion: 6 MWT was a reliable test and positively correlated with all KOOS subscales and negatively correlated with other parameters except height in primary OA knee.
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REVIEW ARTICLE
A practical guide to adult vaccination for patients with autoimmune inflammatory rheumatic diseases in India
Sharath Kumar, Prasandeep Rath, Anand Narayan Malaviya
September 2017, 12(3):160-168
DOI:10.4103/injr.injr_2_17  
Autoimmune inflammatory rheumatic diseases have intrinsic increased risk of infection. The medications used in these diseases may further increase the infection risk. Therefore, vaccinations have gained increasing importance in preventing them in a most cost-effective manner. In this “practical guide,” the vaccines, their schedules, pricing, and the lifetime cost analysis, specifically for the Indian patients, are described in clear, concise language. Case scenarios have been used to further simplify the understanding of the vaccination schedules. This document can be kept in the clinic for day-to-day help in ensuring that the patients are properly covered against these preventable infections.
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Vitamin D and autoimmune diseases
Shir Azrielant, Yehuda Shoenfeld
December 2017, 12(4):219-222
DOI:10.4103/injr.injr_99_17  
Vitamin D and its deficiency are becoming a subject of great interest in recent years. In addition to the well-known role of vitamin D in maintaining bone health, evidence from recent years are accumulating in favor of its importance in the functioning of the immune system. The association between vitamin D deficiency and autoimmune diseases has been supported by epidemiological studies, demonstrating higher prevalence of vitamin D deficiency among autoimmune patients, in comparison to the general population. Vitamin D was also associated to various autoimmune diseases in both molecular and interventional studies; among the associated diseases are: systemic lupus erythematosus, type 1 diabetes mellitus, multiple sclerosis and others. In this review, relevant literature on the association between autoimmunity and vitamin D deficiency will be reviewed and discussed, as well as a summary of important recommendations for vitamin D supplementations in autoimmune patients.
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ORIGINAL ARTICLES
Experience of biological agents usage in patients with rheumatoid arthritis from a Western Indian center
Anuj Singhal, Darshan Bhakuni, Vishal Marwaha, Vivek Hande, Garvit Bagga
September 2016, 11(3):144-148
DOI:10.4103/0973-3698.187412  
Background: In this study the clinical outcomes of different biologics agents in patients with rheumatoid arthritis (RA) has been appraised. Methods: Nineteen RA patients with DMARD failure were administered etanercept (n = 7) or infliximab (n = 12), and 17 RA patients with TNFi failure were administered rituximab (n = 13), abatacept (n = 2), or tocilizumab (n = 2) as per 2013 EULAR guidelines. Baseline demographic details, disease duration, rheumatoid factor, and anticyclic citrullinated peptide antibody were obtained. To monitor disease activity, disease activity score 28-erythrocyte sedimentation rate (DAS28-ESR) score was obtained at baseline, and after 3 months and 6 months of therapy initiation. Results: All the groups were comparable in the baseline. Over 6 months of treatment, the reduction in disease activity, as evidenced by reduction in the mean DAS28-ESR scores was statistically significant for all patients when considered together, as well as when individual biologics were considered separately (P < 0.05 in all cases). However, there was no statistically significant difference in the magnitude of reduction in the mean DAS28-ESR scores between patients who received etanercept and infliximab in DMARD failure RA patients (P = 0.877), or between patients who received rituximab, abatacept, and tocilizumab in TNFi failure patients (P = 0.455). Conclusions: Different biologic agents showed similar efficacy in patients with RA.
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Ultrasonographic evaluation of joint involvement in rheumatoid arthritis: Comparison with conventional radiography and correlation with disease activity parameters
Renu Saigal, Laxmikant Goyal, Hariram Maharia, Meenakshi Sharma, Abhishek Agrawal
March 2017, 12(1):6-11
DOI:10.4103/0973-3698.199123  
Background: Ultrasound (US) including power Doppler (PD) are increasingly being used to evaluate joint involvement in rheumatoid arthritis (RA). Aim of this study was to evaluate joint involvement in RA by US including PD and gray scale imaging and its comparison with conventional radiographic changes and correlation with disease activity parameters. Methods: Patients with RA of less than 3.5 years disease duration were subjected to detailed clinical examination and laboratory investigations. After X-ray imaging (posterior-anterior view) of both hand joints, PD and gray scale US examination of 14 joints of both hands was performed and mean cumulative flow signal score (CFS) was calculated. Disease activity score (DAS28) was also calculated for each patient. Results: Out of total 57 patients evaluated, 54 had abnormal findings on US as compared to only 17 having radiographic abnormalities. US could detect erosions in 29 patients including all of the fourteen patients who had radiographically detectable erosions. On US evaluation, radiocarpal joint was involved most frequently. The mean CFS was 1.17 ± 1.64 in patients who were in remission (DAS28 <2.6), 3.00 ± 3.46 in patients having low disease activity (DAS28 2.6–3.2), 5.25 ± 4.22 in patients with moderate disease activity (DAS28 3.2–5.1), and 6.95 ± 3.84 in patients with high disease activity (DAS28 > 5.1). The difference in CFS among these groups was statistically significant (P < 0.01). In 5 out of 12 patients with DAS28 <2.6, i.e., in remission, CFS were high showing subclinical synovitis. Mean CFS correlated significantly with DAS28 (r = +0.42, P < 0.05); C-reactive protein (r = +0.50, P < 0.05); and erythrocyte sedimentation rate (r = +0.39, P < 0.05). Conclusions: US detected CFS which an indicator of ongoing inflammation in RA patients with clinical remission (DAS28 <2.6). US is more sensitive than conventional radiography for detection of erosions. CFS on PD had a significant correlation with markers of disease activity.
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Rheumatoid arthritis disease activity index-5: Utility in busy clinical settings
Harpreet Singh, Vikram Singh Tanwar, Gagandeep Sukhija, Rekha Mathur, Parminder Kaur
June 2017, 12(2):72-75
DOI:10.4103/0973-3698.199127  
Objective: To assess disease activity using Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5) in patients with rheumatoid arthritis (RA) and its correlation with Disease Activity Score using 28 joint count (DAS28) and Clinical Disease Activity Index (CDAI). Methods: One hundred patients with active RA (as per ACR 1987 criteria) were assessed for disease activity using DAS28, CDAI, and RADAI-5. Spearman's correlation coefficient (ρ) and Cronbach's alpha were measured to assess the correlation between different disease activity scores and internal consistency, respectively. Results: In the study population, 81 patients were women and 19 patients were men. Mean age of the patients was 44.4 (±11.8) years. The median scores (interquartile range) for DAS28, CDAI, and RADAI-5 were 5.6 (2.0), 26.5 (22.0), and 5.8 (3.2), respectively. RADAI-5 was found to be significantly correlated with DAS28 and CDAI (allP < 0.001). Cronbach's alpha was highest for the RADAI-5. Conclusion: RADAI-5 had a positive correlation to DAS28 and CDAI for the assessment of disease activity, and it may be a good alternative to DAS28 and CDAI in busy outdoor settings.
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EDITORIALS
Do we need renal biopsy in patients with lupus nephritis? A rheumatologist's perspective
Gurmeet Singh
March 2017, 12(1):4-5
DOI:10.4103/injr.injr_99_16  
  2,066 177 -
ORIGINAL ARTICLES
Is renal biopsy always necessary to start immunosuppressive therapy in lupus nephritis?
Vasudevan Chelliah, V Balaraman, S Ilango, S Ramesh, V Kannan Bhaba, D Shivakumar
March 2017, 12(1):12-16
DOI:10.4103/0973-3698.199121  
Objective: Most of the patients with proliferative lupus nephritis (LN) have high titer of anti-dsDNA antibody and low complement levels. In this study, we tried to predict proliferative LN with serological profile. Methods: This prospective study was conducted in fifty pateints with known systemic lupus erythematosus (SLE) with laboratory evidence of LN (proteinuria, microscopic hematuria, or increased serum creatinine). Serological profile (anti-dsDNA, C3, and C4) and renal biopsy were done in all patients. Results: Of 50 patients, 35 had Class IV (70%), 7 Class II (14%), 4 Class V (8%), and 4 had Class IV and V (8%) on renal biopsy. Totally, 39 (78%) patients had proliferative LN (Class IV and Class IV and V). The prevalence of anti-dsDNA, low C3, and low C4 was 97.1%, 68%, and 74% with LN and 97.4%, 84.6%, and 87.2% with proliferative LN (P < 0.001), respectively. About 72% (28 of 39 patients) with proliferative LN had the combination of anti-dsDNA positivity, low C3, and low C4 levels. However, whoever had the combination of anti-dsDNA positivity, low C3, and low C4 showed only proliferative LN on biopsy. Positive predictive value was 100% (P < 0.05). None of the patients with Class II or Class V (nonproliferative LN) had this combination of serology. Conclusion: In this study, it was found that proliferative LN can be predicted by serological profile alone. Thus it might be argued that immunosuppressive therapy (steroids and mycophenolate mofetil) may be started without renal biopsy in a known SLE patient with laboratory evidence of LN and positive serology; however, robust studies are required.
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ABSTRACTS
IRACON 2016: Oral Presentations

October 2016, 11(5):2-19
  1,874 178 -
CASE-BASED REVIEW
Carcinomatous polyarthritis as a presenting manifestation of papillary carcinoma of thyroid gland
Himanshu Pathak, Ray Lonsdale, Ketan Dhatariya, Chetan Mukhtyar
September 2016, 11(3):164-166
DOI:10.4103/0973-3698.187411  
A 61-year-old female presented with 6 months of polyarthralgia associated with constitutional symptoms. These included weight loss, night sweats, lethargy and worsening mobility and activities of daily living. There was no significant medical history. On examination, she had synovitis of multiple joints. Investigations for rheumatoid factor and anti-cyclic citrullinated peptide antibody were negative. There was an acute phase response in the form of raised erythrocyte sedimentation rate and C-reactive protein. Contrast-enhanced computed tomography showed pancreatic and right ovarian cystic lesions, which turned out to be clinically insignificant. Positron emission tomography-computed tomography demonstrated fluorodeoxyglucose avid lesion in the right hemi-thyroid. Ultrasound of thyroid gland showed a 13 mm hyporeflective, irregular, subcapsular nodule in the upper lobe with some microcalcification. Fine needle aspiration cytology was diagnostic of papillary carcinoma, confirmed on total thyroidectomy. Arthritis completely resolved within 8 weeks postoperatively. We report the first case of paraneoplastic carcinomatous polyarthritis in association with a papillary thyroid carcinoma as evidenced by a resolution of joint manifestations and laboratory markers of inflammation posttotal thyroidectomy.
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EDITORIALS
Renal biopsy in lupus nephritis: To do or not to do?
Manish Rathi, Aman Sharma, Ritambhra Nada
March 2017, 12(1):2-3
DOI:10.4103/0973-3698.199132  
  1,688 249 -
ORIGINAL ARTICLES
Outcome of therapy in biopsy proven lupus nephritis with cyclophosphamide or mycophenolate: Registry data from a South Indian tertiary care center
Keerthi Talari, Rajendra Varaprasad Irlapati, Megha Uppin, Liza Rajasekhar
June 2017, 12(2):76-80
DOI:10.4103/0973-3698.199126  
Background: Cyclophosphamide and mycophenolate are the currently proposed first-line agents for induction in lupus nephritis (LN). In this study, we analysed the response rates with the three different induction regimens currently available for LN. Methods: Patients with biopsy-proven LN with data available at least till completion of induction regimen was included. Data on demography, clinical, laboratory measures, disease activity, and treatment received at baseline, at the end of induction, and until the last follow-up were retrieved. Response at the end of induction was noted. Differences between groups were analyzed using Chi-square test. Results: Eighty-three patients (75 females) with the mean age of 25 ± 8.9 years were included. The median duration of follow-up was 18 months (range: 6–153). Forty-one patients had Class IV, 19 Class III, 11 Class V, 7 Class III/IV + V, and 5 Class II LN. Forty received high-dose cyclophosphamide (HD CyC), 14 Euro-Lupus Nephritis Trial cyclophosphamide (ELNT CyC), 20 mycophenolate mofetil (MMF) for induction, while two received azathioprine, one cyclosporine, one modified ponticelli, and five with Class II nephritis received no induction. Baseline characteristics were comparable between three groups. The response rate was similar between the three groups: 30/40 in the HD CyC group, 12/14 in the ELNT CyC group, and 15/20 in the MMF group responded at the end of induction (P = 0.69). Complete response rate was higher in the individuals who received cyclophosphamide (HD CyC + ELNT CyC) as compared to MMF (17/34 vs. 2/13, P = 0.05). Univariate analysis of factors predicting response revealed only class of nephritis as a significant factor predicting response (complete or partial) at the end of induction therapy. Conclusion: In this South Indian lupus registry a complete response at 6 months in biopsy-proven LN was better with cyclophosphamide than mycophenolate.
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