***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The treatment of patients with severe lupus nephritis remains controversial . Comparison of treatment outcomes from existing controlled trials is hampered by the heterogeneity of the patient groups with their different intrinsic disease progression . Corticosteroids with cyclophosphamide or azathioprine remain the mainstay of treatment , although meta- analysis has failed to show the superiority of cyclophosphamide over the less toxic azathioprine . The development of safer alternative treatments for the induction of remission of nephritis , long term maintenance , and the management of patient groups refractory to current therapies remains the goal . Mycophenolate mofetil ( MMF ) is one of a number of newer therapies , including ̄udarabine , CTLA4-Ig and anti-C5b under evaluation in lupus nephritis . MMF may potentially offer an alternative for the induction of remission , treatment of refractory , and maintenance of severe lupus nephritis . Controlled trials in renal transplantation have found that MMF reduces the incidence of acute rejection , and is superior to azathioprine when combined with cyclosporin and prednisolone for this indication . The role of MMF in chronic allograft nephropathy is less certain but recently retrospective analysis of data from the US Renal Transplant Registry has shown that MMF decreases the risk of developing chronic allograft failure . This was found to be partly due to MMF decreasing the incidence of acute rejection , but was also caused by an effect independent of acute rejection . The success of MMF in allotransplantation has led to its use in a number of autoimmune diseases and there have been published case series examining its use in Takaysau 's arteritis , refractory uveitis , psoriasis and Crohn 's disease . Recently , reports of MMF in lupus nephritis apparently refractory to cyclophosphamide have been published with encouraging results . The role of MMF for remission induction in severe biopsy proven lupus nephritis , in patients without previous cytotoxic exposure is the subject of several ongoing prospect i ve studies Controlled clinical trials in renal transplantation have demonstrated that mycophenolate mofetil is well tolerated and has lower renal transplant rejection rates than azathioprine regimens . This study reports on the clinical experiences at two institutions with  mycophenolate mofetil ( MMF ) for severe lupus nephritis . Twelve patients with relapsing or resistant nephritis previously treated with cyclophosphamide therapy and one patient who refused cyclophosphamide as initial therapy for diffuse proliferative nephritis but accepted MMF were included . During combined MMF/prednisone therapy , serum creatinine values remained normal or declined from elevated values : mean change in serum creatinine was -0.26+/-0.46 microM/L , P = 0.039 . Proteinuria significantly decreased : mean change in urine protein-to-creatinine ratios was -2.53+/-3.76 , P = 0.039 . Decreased serum complement component C3 and elevated anti-double-str and ed DNA antibody levels at baseline improved in some , but not all , patients . The mean initial dose of  MMF  was 0.92 g/d ( range , 0.5 to 2 g/d ) . The mean duration of therapy was 12.9 mo ( range , 3 to 24 mo ) . Adverse events included herpes simplex stomatitis associated with severe leukopenia ( n = 1 ) , asymptomatic leukopenia ( n = 2 ) , nausea/ diarrhea ( n = 2 ) , thinning of scalp hair ( n = 1 ) , pancreatitis ( n = 1 ) , and pneumonia without leukopenia ( n = 1 ) . Recurrence of the pancreatitis led to discontinuation of MMF in this patient ; all other adverse events resolved with dose reduction . It is concluded that MMF is well tolerated and has possible efficacy in controlling major renal manifestations of systemic lupus erythematosus . Controlled clinical trials are needed to define the role of MMF in the management of lupus nephritis Pulse cyclophosphamide is more effective than prednisone alone in preventing  renal failure in lupus nephritis . We undertook a r and omised , controlled trial to find out whether pulse methylprednisolone could equal pulse cyclophosphamide in preserving renal function in patients with lupus nephritis , and whether there was a difference between long and short courses of pulse cyclophosphamide in preventing exacerbations . 65 patients ( 60 female , 5 male ; median [ range ] age 29 [ 10 - 48 ] years ) with severe lupus nephritis were assigned r and omly to monthly pulse methylprednisolone for 6 months ( 25 patients ) , monthly pulse cyclophosphamide for 6 months ( 20 ) , or monthly cyclophosphamide for 6 months followed by quarterly pulse cyclophosphamide for 2 additional years ( 20 ) . Patients treated with pulse methylprednisolone had a higher probability of doubling serum creatinine than those treated with long-course cyclophosphamide ( p less than 0.04 ) . Risk of doubling creatinine was not significantly different between short and long course cyclophosphamide . However , patients treated with short-course cyclophosphamide had a higher probability of exacerbations than those treated with long-course cyclophosphamide ( p less than 0.01 ) . An extended course of pulse cyclophosphamide is more effective than 6 months of pulse methylprednisolone in preserving renal function in patients with severe lupus nephritis . Addition of a quarterly maintenance regimen to monthly pulse cyclophosphamide reduces the rate of exacerbations BACKGROUND The aim of the present study was to evaluate the efficacy of mycophenolate mofetil in the induction therapy of proliferative lupus nephritis . METHODS Forty-four patients from eight centres with newly diagnosed lupus nephritis World Health Organization class III or IV were r and omly assigned to either mycophenolate mofetil ( MMF ) 2 g/day for 6 months or intravenous cyclophosphamide ( IVC ) 0.75 - 1 g/m(2 ) monthly for 6 months in addition to corticosteroids . RESULTS Remission occurred in 13 out of 25 patients ( 52 % ) in the IVC group and 11 out of 19 patients ( 58 % ) in the MMF group ( P = 0.70 ) . There were 12 % in the IVC group and 26 % in the MMF group that achieved complete remission ( P = 0.22 ) . Improvements in haemoglobin , the erythrocyte sedimentation rate , serum albumin , serum complement , proteinuria , urinary activity , renal function and the Systemic Lupus Erythematosus Disease Activity Index score were similar in both groups . Twenty-four follow-up renal biopsies at the end of therapy showed a significant reduction in the activity score in both groups . The chronicity index increased in both groups but was only significant in the IVC group . Adverse events were similar . Major infections occurred in three patients in each group . There was no difference in gastrointestinal side-effects . CONCLUSIONS MMF in combination with corticosteroids is an effective induction therapy for moderately severe proliferative lupus nephritis Mycophenolate mofetil ( MMF ) and the sequential use of cyclophosphamide followed by azathioprine ( CTX-AZA ) demonstrate similar short-term efficacy in the treatment of diffuse proliferative lupus nephritis ( DPLN ) , but MMF is associated with less drug toxicity . Results from an extended long-term study , with median follow-up of 63 mo , that investigated the role of MMF as continuous induction-maintenance treatment for DPLN are presented . Thirty-three patients were r and omized to receive MMF , and 31 were r and omized to the CTX-AZA treatment arm , both in combination with prednisolone .  More than 90 % in each group responded favorably ( complete or partial remission ) to induction treatment . Serum creatinine in both groups remained stable and comparable over time . Creatinine clearance increased significantly in the MMF group , but the between-group difference was insignificant . Improvements in serology and proteinuria were comparable between the two groups . A total of 6.3 % in the MMF group and 10.0 % of CTX-AZA-treated patients showed doubling of baseline creatinine during follow-up ( P = 0.667 ) . Both the relapse-free survival and the hazard ratio for relapse were similar between MMF- and CTX-AZA-treated patients ( 11 and nine patients relapsed , respectively ) and between those with MMF treatment for 12 or > /=24 mo . MMF treatment was associated with fewer infections and infections that required hospitalization ( P = 0.013 and 0.014 , respectively ) . Four patients in the CTX-AZA group but none in the MMF group reached the composite end point of end-stage renal failure or death ( P = 0.062 by survival analysis ) . It is concluded that MMF and prednisolone constitute an effective continuous induction-maintenance treatment for DPLN in Chinese patients The Phase III Aspreva Lupus Management Study ( ALMS ) will investigate mycophenolate mofetil ( MMF ) therapy for lupus nephritis ( LN ) . Eligibility criteria include : 12—75 years of age ; diagnosis of systemic lupus erythematosus according to revised American College of Rheumatology criteria ; and biopsy-demonstrated LN ( Class III — V ) . R and omized patients will receive open-label induction therapy with MMF or cyclophosphamide in combination with corticosteroids for 24 weeks . The primary efficacy endpoint is treatment response [ decreased proteinuria and stabilized ( within 25 % of baseline ) or improved serum creatinine level ] . Patients achieving response or complete remission ( normalization of all parameters ) will be rer and omized to double-blind , placebo-controlled maintenance treatment with MMF or azathioprine , both plus corticosteroids . The maintenance phase primary endpoint is time to treatment failure . To detect a 15 % rate improvement in the MMF group compared with cyclophosphamide , and to provide 90 % power , a total of 358 patients will be required for the induction phase . On the basis of a projected 278 rer and omized patients , the maintenance phase will have 90 % power to detect a difference between treatment groups assuming azathioprine and MMF three-year failure rates of 59.5 % and 40.7 % , respectively . Aspreva Lupus Management Study may provide invaluable comparative data on the efficacy and safety of MMF as LN induction and maintenance therapy . Lupus ( 2007 ) 16 , 972—980 OBJECTIVE To make an open label prospect i ve trial for comparing the therapeutic effects of mycophenolate mofetil ( MMF ) vs cyclophosphamide ( CYC ) pulse therapy on patients with diffuse proliferative lupus nephritis ( DPLN ) . METHODS Forty-six patients with biopsy proven active DPLN were enrolled in this study . Twenty-three patients were given MMF orally at a dosage of 1.0 - 1.5 g/d ( MMF Group ) . Another 23 cases received conventional intermittent CYC pulse therapy ( CYC Group ) . Supplemental steroid treatment was offered in the same manner to both groups . The age , sex distribution and severity of renal damage were matched in two groups . Therapeutic effects were evaluated at the end of six-month treatment . Fifteen patients in the MMF Group and 12 patients in the CYC Group had repeated renal biopsy at that time . RESULTS MMF therapy was more effective in reducing proteinuria and hematuria . A 50 % reduction of urinary protein and urinary red blood cell excretion from baseline value in 69.6 % and 91.3 % patients in the MMF Group , while only 47.8 % and 65.2 % in the CYC Group . MMF was more effective in inhibiting autoantibody production ( especially anti-dsDNA antibody ) and in decreasing serum cryoglobulin levels . Pathologically , the MMF group showed more markedly reduction in glomerular immune deposits with less glomerular necrosis , and less microthrombi , less crescent formation and vascular changes in the repeated renal biopsy as compared with the CYC group . Adverse reactions related to the treatment included gastrointestinal symptoms 26.1 % and 43.5 % in the MMF and CYC Groups respectively , infection 17.4 % in the MMF group and 30.4 % in the CYC group . CONCLUSION MMF was more effective in controlling the clinical activity of DPLN and renal vascular lesions as compared with CYC pulse therapy in a 6 month follow-up study Table . Drugs and Abbreviation Ovarian toxicity is an important consideration before the use of  cyclophosphamide therapy in premenopausal women [ 1 ] . The deleterious effects of cyclophosphamide on ovarian function were noted in patients with rheumatoid arthritis treated with daily oral cyclophosphamide  [ 2 ] . These preliminary observations have been confirmed and extended by subsequent studies in patients with various immune-mediated diseases including rheumatoid arthritis [ 3 ] , systemic lupus erythematosus [ 4 - 6 ] , ren 
    Output:
    
Treatment of lupus nephritis with mycophenolate mofetil compared with cyclophosphamide reduces the risk for failure to induce remission during induction therapy and may reduce the risk for death or end-stage renal disease .
Mycophenolate mofetil may be considered as a first-line induction therapy for the treatment of lupus nephritis in patients without severe renal dysfunction