Original Investigation | Rheumatology

Effect of Tacrolimus vs Intravenous Cyclophosphamide on Complete or Partial

Response in Patients With Lupus Nephritis
A Randomized Clinical Trial
Zhaohui Zheng, MD; Haitao Zhang, MD; Xiaomei Peng, MD; Chun Zhang, MD, PhD; Changying Xing, MD; Gang Xu, MD; Ping Fu, MD; Zhaohui Ni, MD; Jianghua Chen, MD;
Zhonggao Xu, MD; Ming-hui Zhao, MD; Shaomei Li, MD; Xiangyang Huang, MD; Lining Miao, MD; Xiaonong Chen, MD; Bicheng Liu, MD; Yongcheng He, MD; Jing Li, MSc;
Lijun Liu, MD; Haishan Kadeerbai, MS; Zhangsuo Liu, MD; Zhihong Liu, MD

Abstract Key Points

Question What is the efficacy and
IMPORTANCE Lupus nephritis (LN) is typically treated with intravenous cyclophosphamide (IVCY),
safety of tacrolimus vs intravenous
which is associated with serious adverse effects. Tacrolimus may be an alternative for initial
cyclophosphamide (IVCY) as initial
treatment of LN; however, large-scale, randomized clinical studies of tacrolimus are lacking.
therapy for lupus nephritis (LN) among
Chinese patients?
OBJECTIVE To assess efficacy and safety of tacrolimus vs IVCY as an initial therapy for LN in China.
Findings In this randomized clinical trial
DESIGN, SETTING, AND PARTICIPANTS This randomized (1:1), open-label, parallel-controlled, of 299 patients, the complete or partial
phase 3, noninferiority clinical trial recruited patients aged 18 to 60 years with systemic lupus kidney response rate was 83.0% with
erythematosus and LN class III, IV, V, III+V, or IV+V primarily from outpatient settings at 35 centers in tacrolimus vs 75.0% with IVCY after 24
China. Inclusion criteria included body mass index of 18.5 or greater to less than 27, 24-hour urine weeks of treatment, and tacrolimus was
protein of 1.5 g or greater, and serum creatinine of less than 260 μmol/L. Of 505 patients screened, statistically noninferior to IVCY
191 failed screening (163 ineligible, 25 withdrawn consent, and 3 other reasons). Overall, 314 were regarding response rate. The incidence
randomized. The first patient was enrolled March 10, 2015, and the study finished September 13, and type of treatment-emergent
2018. The follow-up period was 24 weeks. Data were analyzed from December 2019 to March 2020. adverse events reported were as
expected in the patient population.
INTERVENTIONS Oral tacrolimus (target trough level, 4-10 ng/mL) or IVCY for 24 weeks plus
Meaning These findings suggest that
prednisone.
tacrolimus may be an alternative to IVCY
as an initial therapy for LN.
MAIN OUTCOMES AND MEASURES Complete or partial response rate at week 24 (prespecified).

RESULTS A total of 314 patients were randomized (158 [50.3%] to tacrolimus and 156 [49.7%] to + Visual Abstract
IVCY). Overall, 299 patients (95.2%) were treated (tacrolimus group, 157 [52.5%]; IVCY group, 142
[47.5%]). Baseline demographic and clinical characteristics were generally similar between groups
+ Supplemental content
Author affiliations and article information are
(mean [SD] age, 34.2 [9.5] years; 262 [87.6%] female). Tacrolimus was found to be noninferior to
listed at the end of this article.
IVCY for LN response at week 24. There was a complete or partial response rate of 83.0% (117 of 141
patients) in the tacrolimus group and 75.0% (93 of 124 patients) in the IVCY group (difference, 7.1%;
2-sided 95% CI, −2.7% to 16.9%; lower limit of 95% CI greater than −15%). At week 24, least-square
mean change in Systemic Lupus Erythematosus Disease Activity Index score was −8.6 with
tacrolimus and −6.4 with IVCY (difference, −2.2; 95% CI, −3.1 to −1.3). Changes in other immune
parameters and kidney function were generally similar between groups. Serious treatment-emergent
adverse events (TEAEs) were reported in 29 patients in the tacrolimus group (18.5%) and 35 patients
in the IVCY group (24.6%). Most common serious study drug-related TEAEs were infections (14
[8.9%] and 23 [16.2%], respectively). Seven patients in each group withdrew due to AEs.

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY-NC-ND License.

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

Abstract (continued)

CONCLUSIONS AND RELEVANCE In this study, oral tacrolimus appeared noninferior to IVCY for
initial therapy of active LN, with a more favorable safety profile than IVCY. Tacrolimus may be an
alternative to IVCY as initial therapy for LN.

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02457221

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Introduction
Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease, with an
estimated prevalence in China of 30 to 50 per 100 000 population.1 Kidney involvement in SLE has
implications for disease management and prognosis. As many as 60% of patients with SLE develop
lupus nephritis (LN).1-3 LN is associated with substantial morbidity and mortality3,4 and is an
important cause of chronic kidney disease and kidney failure in Asia.5,6 The goal of treatment is to
preserve kidney function and limit progression to end-stage kidney disease, thus preventing the
need for dialysis and transplantation.3,7 Combination therapy with high-dose corticosteroids and
intravenous cyclophosphamide (IVCY) is an established initial therapy among patients with LN.7-10
However, CY is cytotoxic, and serious adverse effects have been observed during long-term
treatment, including premature ovarian failure.11,12
The calcineurin inhibitor (CNI) tacrolimus may be considered an alternative to IVCY for initial
treatment of LN.7-10 Tacrolimus hinders T-cell activation, thereby suppressing autoantibody
production and preventing long-term kidney damage.13 In addition to attenuating glomerular
deposition of immune complexes, tacrolimus may have direct protective effects on podocytes,
including stabilization of the actin cytoskeleton and inhibition of podocyte apoptosis, which could
contribute to preservation of kidney function in patients with LN.14 Tacrolimus may also be
steroid-sparing,15,16 which could reduce the adverse effect burden.
Significantly reduced LN disease activity index was observed in patients treated with tacrolimus
over 28 weeks in a placebo-controlled phase 3 study in Japan.17 Studies have also shown that initial
therapy with tacrolimus plus corticosteroids is at least as effective and well-tolerated as IVCY for
LN.18-21 Indeed, a recent network meta-analysis found CNIs, alone or in combination with
mycophenolate mofetil (MMF), to be more effective than IVCY for inducing response in patients with
LN, with similar or lower treatment toxic effects.22 However, large-scale, randomized clinical studies
of initial therapy with tacrolimus vs IVCY are lacking. We report results of a phase 3 study undertaken
to evaluate the efficacy and safety of tacrolimus vs IVCY in combination with corticosteroids as initial
therapy for LN in Chinese patients.

Methods
This report follows the Consolidated Standards of Reporting Trials (CONSORT) guideline for
reporting of randomized trials. The study protocol is included in Supplement 1.

Study Design and Participants

This randomized, open-label, parallel-controlled, multicenter, phase 3 noninferiority study was
undertaken at 35 centers in China (2 centers did not enroll patients). The study was approved by the
independent ethics committee or institutional review board at each site and was conducted in
accordance with the International Conference on Harmonisation guideline on Good Clinical Practice
and applicable local laws and regulations. Written informed consent was obtained from patients prior
to study participation.

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

Patients were recruited primarily from outpatient settings based on eligibility and willingness to
participate. Eligible patients were aged 18 to 60 years (body mass index [calculated as weight in
kilograms divided by height in meters squared] ⱖ18.5 but <27) with SLE (according to American
Rheumatism Association Diagnostic Criteria and proven by kidney biopsy within 24 weeks before
enrollment)23 and were categorized as LN class III, IV, V, III+V, or IV+V (International Society of
Nephrology/Renal Pathology Society classification).24 Patients were also required to have 24-hour
proteinuria of 1.5 g or greater and serum creatinine (SCr) levels less than 260 μmol/L (to convert to
milligrams per deciliter, divide by 88.4). Exclusion criteria are listed in eTable 1 in Supplement 2. The
first patient was enrolled on March 10, 2015; the study finished on September 13, 2018.

Randomization and Treatment

Eligible patients were randomized (1:1) via a centralized randomization system using interactive
response technology to treatment with tacrolimus or IVCY for 24 weeks. Randomization was
stratified according to LN class (III, IV, V, III+V, or IV+V). All patients received intravenous
methylprednisolone pulse therapy (0.5 g/d for 3 days) prior to starting study treatment, followed by
oral prednisone (initiated at 0.8 mg/kg/d [maximum dose 45 mg/d] for 4 weeks, then tapered by 5
mg/d every 2 weeks to 20 mg/d, then by 2.5 mg/d every 2 weeks to a maintenance dose of 10 mg/d,
which was then maintained in both groups until 24 weeks). Oral tacrolimus was initiated at a dose of
4 mg/d, administered in 2 divided doses; dose adjustments were permitted after day 14 to maintain
tacrolimus trough levels of 4 to 10 ng/mL. The starting dose of IVCY was 0.75 g/m2 body surface area
(BSA); thereafter, the target was 0.5 to 1.0 g/m2 BSA every 4 weeks, with dose adjustments of 0.25
g/m2 permitted to maintain white blood cell (WBC) count above 2500 to 4000 cells/μL (to convert
to cells × 109 per liter, multiply by 0.001). IVCY treatment could be suspended because of adverse
events or other specific conditions at the investigator’s discretion.

Outcomes
Patients were assessed at visits at weeks 1, 2, 4, 8, 12, 16, 20, and 24. The primary efficacy end point
was the proportion of patients who achieved a response (complete or partial) at week 24. Complete
response was defined as proteinuria of less than 0.5 g per 24 hours, serum albumin of 3.5 g/dL or
greater (to convert to grams per liter, multiply by 10), and stable kidney function (ie, SCr in the
reference range or an increase of ⱕ15% from baseline). Partial response was defined as proteinuria
of less than 3.5 g per 24 hours and decreased by more than 50% from baseline, serum albumin of 3.0
g/dL or greater, and stable kidney function. Secondary efficacy assessments included Systemic Lupus
Erythematosus–Disease Activity Index (SLEDAI) score, immune parameters (serum complement C3
and C4, and anti-double-stranded DNA [dsDNA] antibodies), and kidney function (24-hour
proteinuria, serum albumin and SCr levels, and estimated glomerular filtration rate [eGFR, based on
Chronic Kidney Disease Epidemiology Collaboration formula]). Unless otherwise stated, values are
expressed as means and SDs.
Treatment-emergent adverse events (TEAEs) were summarized by preferred terms (Medical
Dictionary for Regulatory Activities, version 17.0). TEAEs were considered serious if they resulted in
death, were life-threatening, required hospitalization or prolongation of existing hospitalization,
resulted in persistent or significant disability or incapacity, or resulted in congenital anomaly or
birth defect.

Statistical Analysis
The sample size was based on the results of a randomized, placebo-controlled, phase 3 study of
tacrolimus for LN in Japan,17 in which the response rates were 2.9% and 46.4% in the placebo and
tacrolimus groups, respectively (data on file). Tacrolimus was assumed to have the same efficacy as
IVCY (namely, a treatment effect of 43.5%), and the noninferiority margin was therefore set at 15% to
ensure that tacrolimus would retain at least two-thirds of the expected effect of IVCY. Previous
studies have shown response rates of 70% to 100% in patients with LN receiving tacrolimus or IVCY

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initial therapy19,20; the response rate for tacrolimus and IVCY in this study was therefore assumed to
be 80%. It was estimated that 125 patients per group would yield 80% power to show noninferiority;
planned enrollment was 294 patients, allowing for 15% attrition.
Safety was assessed in all randomized patients who received at least 1 dose of study drug.
Efficacy was assessed according to a modified intention-to-treat approach. The full analysis set (FAS)
included all patients from the safety population with any efficacy data. However, given that use of
the FAS tends to favor a noninferiority conclusion, efficacy was assessed in the per-protocol set
(PPS), comprising patients from the FAS with at least 12 weeks (ie, 85 ± 5 days) of follow-up
(including early withdrawals due to lack of efficacy), who were compliant with medication (taking
80%-120% of required number of tablets) and had no major protocol deviations.
The Cochran-Mantel-Haenszel test was used for the primary efficacy analysis, with adjustment
for baseline stratification by LN class. For the primary end point, noninferiority was concluded if the
lower limit of the 95% CI of the difference in response rate between tacrolimus and IVCY was greater
than −15%. To confirm robustness of the primary analysis and assess consistency of the primary
efficacy outcome among subpopulations, sensitivity and subgroup analyses of the primary end point
were undertaken (eTable 2 in Supplement 2). Sensitivity analyses of response rate were carried out
for the FAS (last observation carried forward) and for the FAS/PPS based on response assessment in
week 24 and response derived from laboratory test data. Subgroup analyses were performed for the
primary end point according to sex, baseline BSA, LN class and duration, and SLEDAI score.
Secondary efficacy end points were intended to provide supportive evidence relating to the
primary objective and hence were assessed without adjustment for multiple comparisons. They were
compared between groups by analysis of covariance, with treatment group, baseline value, and
stratification factor (pathological type) as fixed effects. Missing data for response were imputed by
last observation carried forward. All statistical tests were 2-sided, with a significance level of .05;
associated P values are intended to be read descriptively. Analyses were performed using SAS
version 9.4 (SAS Institute). Data were analyzed from December 2019 to March 2020.

Results
Patients
Patient disposition is summarized in Figure 1. Of the 505 patients screened, 314 (158 [50.3%] in
tacrolimus group; 156 [49.7%] in IVCY group) were randomized, and 299 received study treatment
(157 [52.5%] in tacrolimus group; 142 [47.5%] in IVCY group). Baseline demographic and clinical
characteristics were generally similar between the 2 groups (Table 1). Patients were predominantly
female (262 [87.6%]), had a mean (SD) age of 34.2 (9.5) years (range, 18-58 years), and
predominantly had LN class IV (122 [40.8%]) or class IV+V (85 [28.4%]). The PPS included 265
patients (141 [53.2%] in the tacrolimus group; 124 [46.8%] in the IVCY group). Overall, 263 patients
completed the study (141 [53.6%] in the tacrolimus group; 122 [46.4%] in the IVCY group). The most
common reasons for discontinuation were adverse events (7 patients in each group) and withdrawal
of consent (1 patient in tacrolimus group and 6 patients in IVCY group).

Treatment
Mean medication compliance was 99% in both treatment groups (eTable 3 in Supplement 2). Mean
duration of exposure was similar in both groups (159.6 vs 153.5 days, respectively). Mean (SD) blood
concentration of tacrolimus throughout the study was 5.3 (2.0) ng/mL (<4 ng/mL in 43 patients
[27.4%]; 4-10 ng/mL in 109 [69.4%]; and >10 ng/mL in 3 [1.9%]). There was no notable difference in
daily dosage or total dosage of oral prednisone between the 2 groups.

Response Rate
Tacrolimus was noninferior to IVCY for response of LN at week 24 (Table 2). At 24 weeks, the rate of
complete response was 70 (49.6%) and 45 (36.3%) and the rate of partial response was 47 (33.3%)

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

and 48 (38.7%) in the tacrolimus and IVCY groups, respectively. The rate of complete or partial
response was 83.0% (117 patients) with tacrolimus and 75.0% (93 patients) with IVCY (difference
between groups, 7.1%; 2-sided 95% CI, −2.7% to 16.9%; lower limit of the 95% CI greater than −15%).
Sensitivity analyses confirmed robustness of the primary analysis (eTable 4 in Supplement 2).
Response rates were numerically higher in the tacrolimus group than in the IVCY group when split by
sex, BSA at baseline, duration of LN, SLEDAI score at baseline (data not shown), and pathological
type of LN (except in patients with type IV+V disease) (eTable 5 in Supplement 2). In patients with
type V disease, the response rate at week 24 was 68.4% in the tacrolimus group (13 patients) vs
44.4% in the IVCY group (8 patients; difference between groups, 24.0%; 2-sided 95% CI, −7.3%
to 49.6%).

SLEDAI Score
Mean SLEDAI score decreased in both groups over the study period (eFigure 1 in Supplement 2), was
less than 10 in both groups at week 4, and was less than 4 in the tacrolimus group at week 24. At
week 12, least-square mean (LSM) change in SLEDAI score was −6.7 with tacrolimus and −5.7 with
IVCY (LSM difference, −1.0; 95% CI, −1.8 to −0.1; P = .02). At week 24, LSM change in SLEDAI score
was −8.6 with tacrolimus and −6.4 with IVCY (LSM difference, −2.2; 95% CI, −3.1 to −1.3; P < .001).

Immune Parameters
No significant differences were seen between groups in mean change from baseline to week 24 for
serum C3 and C4 (eFigure 2 in Supplement 2). Mean C3 levels returned to reference range (0.9-1.8
g/L) from week 4 in the tacrolimus group and week 12 in the IVCY group; mean C4 levels were within
the reference range (0.1-0 4 g/L) in both groups throughout the study. Anti-dsDNA antibody
converted from positive to negative by week 24 in 37 patients (26.2%) and 26 patients (21.0%) in the
tacrolimus and IVCY groups, respectively (P = .33).

Figure 1. Study Flowchart

505 Patients assessed for eligibility

191 Excluded
163 Did not meet inclusion criteria
25 Withdrew consent
3 Other reasons

314 Randomized

158 Randomized to tacrolimus 156 Randomized to IVCY

157 Received intervention (SAF) 142 Received intervention (SAF)
1 Did not receive intervention 14 Did not receive intervention

157 Included in the FAS 142 Included in the FAS

16 Discontinued intervention 20 Discontinued intervention

7 Withdrew because of adverse event 7 Withdrew because of adverse event
3 Protocol deviation 6 Withdrew consent
1 Death 2 Pregnant IVCY indicates intravenous cyclophosphamide; FAS,
1 Withdrew consent 1 Protocol deviation full analysis set; PPS, per-protocol set; SAF, safety set.
1 Study terminated by spsonsor 1 Death a
PPS comprised patients from the FAS with at least 12
1 Noncompliant with study drug 1 Lost to follow-up
1 Pregnant 2 Other reasons weeks (85 ± 5 days) of follow-up (including early
1 Other reason withdrawals due to lack of efficacy) who were
compliant with medication (taking 80%-120% of
required number of tablets) and had no major
141 Included in the PPSa 124 Included in the PPSa
protocol deviations.

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Kidney Function
Tacrolimus was associated with significant improvement in mean 24-hour proteinuria vs IVCY
(Figure 2A). LSM reductions in 24-hour proteinuria from baseline were significantly greater with
tacrolimus vs IVCY at all visits from week 4 onwards (P < .001). At week 24, LSM change in 24-hour
proteinuria from baseline was −4534.8 mg and −3632.5 mg in the tacrolimus and IVCY groups,
respectively (LSM difference, −902.3 mg; 95% CI, −1382.2 to −422.3 mg; P < .001). Mean change
from baseline to week 24 in serum albumin was similar between groups (Figure 2B). Differences in
mean SCr level (Figure 2C) and eGFR were seen between the 2 groups over the study period but
remained within the reference range in both groups at all visits (eTable 6 in Supplement 2). At week
24, LSM change in SCr level from baseline was 10.2 μmol/L with tacrolimus and −5.6 μmol/L with IVCY
(LSM difference, 15.9 μmol/L; 95% CI, 6.7 to 25.1 μmol/L; P < .001). Doubling of SCr level from
baseline within 24 weeks occurred in 9 patients in the tacrolimus group (4 patients outside the

Table 1. Patient Demographics and Baseline Clinical Characteristics in the Full Analysis Set

Participants by treatment group, mean (SD)

Parameter Tacrolimus (n = 157) IVCY (n = 142) Total (N = 299)
Age, y 34.3 (9.6) 34.1 (9.4) 34.2 (9.5)
Female, No. (%) 138 (87.9) 124 (87.3) 262 (87.6)
Male, No. (%) 19 (12.1) 18 (12.7) 37 (12.4)
BSA, m2 1.6 (0.1) 1.6 (0.1) 1.6 (0.1)
BMI 22.3 (2.5) 22.5 (2.4) 22.4 (2.5)
Duration of LN, mean (SD) [range] y 1.4 (3.3) [0.0-17.8] 1.5 (4.0) [0.1-25.2] 1.4 (3.7) [0.0-25.2]
Pathological type, No. (%)
III 8 (5.1) 8 (5.6) 16 (5.4)
IV 64 (40.8) 58 (40.8) 122 (40.8)
V 22 (14.0) 20 (14.1) 42 (14.0)
III+V 17 (10.8) 17 (12.0) 34 (11.4)
IV+V 46 (29.3) 39 (27.5) 85 (28.4)
SLEDAI score 11.9 (5.6) 12.6 (5.1) 12.3 (5.3)
ESR, mm/h 36.3 (28.0) 33.3 (25.0) 34.8 (26.6)
Abbreviations: ACEi, angiotensin converting enzyme
Anti-dsDNA antibody positive, No. (%) 84 (53.5) 91 (64.1) 175 (58.5)
inhibitor; ARB, angiotensin II receptor blocker; BMI,
Anti-dsDNA antibody, IU/mL 275.0 (467.6) 288.3 (358.4) 281.3 (424.0) body mass index (calculated as weight in kilograms
C3, g/L 0.62 (0.30) 0.60 (0.25) 0.61 (0.28) divided by height in meters squared); BSA, body
C4, g/L 0.12 (0.07) 0.11 (0.06) 0.11 (0.07) surface area; C3, complement C3; C4, complement C4;
Kidney biopsy activity index scorea 7.8 (3.9) 7.6 (3.8) 7.7 (3.9) dsDNA, double-stranded DNA; eGFR, estimated
glomerular filtration rate; ESR, erythrocyte
Kidney biopsy chronicity index scoreb 2.5 (1.3) 2.5 (1.3) 2.5 (1.3)
sedimentation rate; IVCY, intravenous
24-hour urine protein, mg 5805.7 (3538.3) 5347.9 (3441.5) 5588.3 (3494.3) cyclophosphamide; LN, lupus nephritis; SCr, serum
Serum albumin, g/dL 2.3 (0.7) 2.4 (0.7) 2.4 (0.7) creatinine; SLEDAI, Systemic Lupus Erythematosus
SCr, μmol/L 75.8 (39.2) 70.8 (35.0) 73.4 (37.3) Disease Activity Index.
SCr >132.6 μmol/L, No. (%) 13 (8.3) 9 (6.3) 22 (7.4) SI conversion factors: To convert serum albumin to
eGFR, mL/min/1.73 m2 99.4 (33.4) 103.4 (30.6) 101.3 (32.1) grams per liter, multiply by 10; SCr to milligrams per
deciliter, divide by 88.4.
eGFR<60 mL/min/1.73 m2, No. (%) 25 (15.9) 16 (11.3) 41 (13.7)
a
Based on available data: 150 and 131 for the
Concomitant ACEi/ARB use, No. (%)
tacrolimus and IVCY groups, respectively (281 total).
ACEi 19 (12.1) 16 (11.3) 35 (11.7)
b
Based on available data: 116 and 93 for the tacrolimus
ARB 55 (35.0) 52 (36.6) 107 (35.8)
and IVCY groups, respectively (209 total).

Table 2. Response Rate at Week 24 in the Per-Protocol Set

Participants by treatment group, No. (%)

% Difference between tacrolimus
Parameter Tacrolimus (n = 141) IVCY (n = 124) and IVCY groups, (95% CI)
Complete response 70 (49.6) 45 (36.3) NA
Partial response 47 (33.3) 48 (38.7) NA
Abbreviations: IVCY, intravenous cyclophosphamide;
Response rate 117 (83.0) 93 (75.0) 7.1 (−2.7 to 16.9)
NA, not applicable.

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Figure 2. Mean Change From Baseline to Week 24 for 24-Hour Urine Protein, Serum Albumin Level, and Serum Creatinine Level in the Per-Protocol Set

A 24-h Urine protein

0
Mean change in 24-h urine protein,

–1200

–2400
mg/24 h

IVCY
–3600

–4800
Tacrolimus

–6000
Baseline Day 4 8 12 16 20 24
1
Week

Time
No. at risk
Tacrolimus 141 127 141 141 141 141 141 141
IVCY 124 116 124 124 124 124 124 124

B Serum albumin
16
Tacrolimus
Mean change in serum albumin, g/L

14

12 IVCY

10

0
Baseline Day 1 2 4 8 12 16 20 24
1
Week

Time
No. at risk
Tacrolimus 141 135 141 141 141 141 141 141 141 141
IVCY 124 117 123 124 124 124 124 124 124 124

C Serum creatinine
16
Mean change in serum creatinine,

12
Tacrolimus
8

4
μmol/L

–4
IVCY
–8

–12
Baseline Day 1 2 4 Week 4 Week 12 Week 16 Week 20 Week 24
1
Week

Time
No. at risk
Tacrolimus 141 135 141 141 141 141 141 141 141 141
IVCY 124 117 123 124 124 124 124 124 124 124

IVCY indicates intravenous cyclophosphamide. Whiskers indicate SEs. To convert serum albumin to grams per liter, multiply by 10; serum creatinine to milligrams per deciliter, divide by 88.4.

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

reference creatinine range) and none in the IVCY group. LSM change in eGFR from baseline at week
24 was −8.8 mL/min/1.73 m2 with tacrolimus and 4.3 mL/min/1.73 m2 with IVCY (LSM difference, −13.1
mL/min/1.73 m2; 95% CI, −17.9 to −8.4 mL/min/1.73 m2; P < .001).

Safety
A similar proportion of patients experienced TEAEs in both groups (Table 3). Most (>70%) TEAEs
were mild or moderate in severity. The most common study drug-related TEAEs were upper
respiratory tract infection (37 [23.6%]) and diarrhea (16 [10.2%]) in the tacrolimus group, and upper
respiratory tract infection (40 [28.2%]), nausea (34 [23.9%]), vomiting (33 [23.2%]), alopecia (17
[12.0%]), and decreased WBC count (16 [11.3%]) in the IVCY group. Serious TEAEs were reported in
29 patients (18.5%) in the tacrolimus group and 35 patient (24.6%) in the IVCY group. The proportion
of patients with serious TEAEs considered to be study drug–related was numerically lower in the
tacrolimus group than in the IVCY group (18 [11.5%] vs 30 [21.1%]). The most common serious study
drug–related TEAE was infection (mainly lung and upper respiratory tract infections), reported in 14
patients (8.9%) and 23 patients (16.2%) in the tacrolimus and IVCY groups, respectively. Three
TEAEs resulted in 2 deaths (1 in the tacrolimus group due to varicella; 1 in the IVCY group due to septic
shock and pneumonia), both considered treatment-related.

Discussion
To our knowledge, this is the first large-scale, randomized clinical trial to assess the safety and
efficacy of tacrolimus vs IVCY in patients with LN. Results show initial therapy with tacrolimus to be
noninferior to IVCY regarding response rate after 24 weeks of treatment (83.0% vs 75.0% in the
tacrolimus and IVCY groups, respectively). Results of this study are consistent with those of previous
small-scale studies of tacrolimus vs IVCY for initial treatment of LN, although findings should be
compared with caution due to differences in patient populations, primary end point definitions, and
treatment dosing regimens between studies.18-21 The response rate with tacrolimus in the present
study (83.0%) is also aligned with that reported in a randomized clinical trial undertaken to compare
the efficacy of tacrolimus vs MMF as LN initial therapy (overall response rate at 6 months, 89% in
the tacrolimus group vs 80% in the MMF group).25 In another Chinese study, Liu et al26 investigated
the efficacy and safety of combined therapy with tacrolimus (4 mg/d) and MMF (1 g/d) vs IVCY
(initiated at 0.75 g/m2 BSA and then adjusted to 0.5-1.0 g/m2 BSA) as initial therapy for adult patients
with LN class III, IV, V, III+V, or IV+V disease. The complete or partial response rates at 6 months were
83.5% vs 63.0%, respectively.26 However, caution should be exercised when comparing data from
our study with those from the study by Liu et al,26 as patients in the tacrolimus group from our study
did not receive MMF.
Notably, tacrolimus demonstrated a clinically meaningful improvement in SLEDAI score vs IVCY
from week 12. Tacrolimus was also associated with a clinically meaningful improvement in 24-hour
proteinuria compared with IVCY, which may suggest a more favorable long-term kidney outcome in
patients with LN.27,28 This is consistent with findings from other studies, in which more rapid
reduction in proteinuria was seen in patients with LN who received therapy with tacrolimus vs with
IVCY.19,20 These findings suggest that kidney response may be more rapidly achieved during initial
therapy with tacrolimus than IVCY.
In this study, after 24 weeks’ treatment, the LSM change from baseline in SCr level was higher
in the tacrolimus group than in the IVCY group (10.2 vs −5.6 μmol/L). However, this change was not
clinically relevant. As might be expected, the mean SCr level was elevated in the tacrolimus group
throughout the study, but it did not exceed 15% of the mean baseline level, remaining within the
reference range across visits. This elevation in SCr level is not thought to be caused by lupus disease
but may be related to tacrolimus treatment, given that similar trends have been observed in previous
studies. For example, in the 28-week study by Miyasaka et al,17 median creatinine clearance
decreased from 101.4 mL/min at baseline to 78.2 mL/min at the final assessment in the tacrolimus

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group, while baseline and final creatinine clearance were similar in the placebo group. Furthermore,
Szeto et al29 reported lower (although not statistically significantly lower) eGFR after 24 weeks of
tacrolimus treatment vs control. The effect of tacrolimus on SCr level may be influenced by drug dose
and blood concentration. As the target trough concentration of tacrolimus in our study was 4 to 10

Table 3. Summary of Patients Experiencing TEAEs Over the 24-Week Study Period in the Safety Population

Participants in safety population, No. (%)

Tacrolimus
TEAE parameter (n = 157) IVCY (n = 142)
Any TEAE 145 (92.4) 136 (95.8)
TEAE related to study drug 118 (75.2) 120 (84.5)
Study drug–related TEAES reported in ≥5% of patients in either groupa
Abdominal distension 6 (3.8) 8 (5.6)
Alopecia 5 (3.2) 17 (12.0)
Bronchitis 8 (5.1) 10 (7.0)
Cough 11 (7.0) 7 (4.9)
Diarrhea 16 (10.2) 2 (1.4)
Granulocytopenia 0 9 (6.3)
Headache 4 (2.5) 8 (5.6)
Herpes zoster 4 (2.5) 14 (9.9)
Hyperuricemia 13 (8.3) 5 (3.5)
Leukopenia 0 12 (8.5)
Hepatic function abnormal 8 (5.1) 10 (7.0)
Hypokalemia 3 (1.9) 8 (5.6)
Lung infection 8 (5.1) 11 (7.7)
Nausea 4 (2.5) 34 (23.9)
Tremor 15 (9.6) 2 (1.4)
Upper respiratory tract infection 37 (23.6) 40 (28.2)
Urinary tract infection 9 (5.7) 6 (4.2)
Vomiting 2 (1.3) 33 (23.2)
WBC count decreased 2 (1.3) 16 (11.3)
Any serious TEAE 29 (18.5) 35 (24.6)
Any serious TEAE related to study drug 18 (11.5) 30 (21.1)
Serious study drug–related TEAEs reported by >1 patient in either groupb
Infections and infestations
Any 14 (8.9) 23 (16.2)
Lung infection 5 (3.2) 10 (7.0)
Upper respiratory tract infection 3 (1.9) 4 (2.8)
Pneumonia 2 (1.3) 2 (1.4)
Bronchitis 2 (1.3) 1 (0.7)
Pulmonary tuberculosis 0 2 (1.4)
Blood and lymphatic system disorders
Any 0 4 (2.8)
Granulocytopenia 0 2 (1.4)
Gastrointestinal disorders 1 (0.6) 2 (1.4)
General disorders and administration site conditions
Abbreviations: IVCY, intravenous cyclophosphamide;
Any 0 2 (1.4)
TEAE, treatment-emergent adverse event; WBC, white
Pyrexia 0 2 (1.4) blood cell.
Respiratory, thoracic, and mediastinal disorders 2 (1.3) 0 a
TEAEs were recorded using Medical Dictionary for
Any TEAE leading to early withdrawal 19 (12.1) 16 (11.3) Regulatory Activities preferred terms and are listed
TEAE related to study drug leading to early withdrawal 16 (10.2) 13 (9.2) alphabetically.
b
Any serious TEAE leading to early withdrawal 11 (7.0) 9 (6.3) Serious TEAEs were recorded using Medical
Any serious TEAE related to study drug leading to early withdrawal 9 (5.7) 7 (4.9) Dictionary for Regulatory Activities system organ
class and preferred terms and are listed
Any TEAE leading to death 1 (0.6) 1 (0.7)
alphabetically.

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

ng/mL and the mean (SD) tacrolimus trough concentration was 5.3 (2.0) ng/mL, these data remind
clinicians to monitor kidney function even within normal drug concentration ranges. Since this was a
24-week study, long-term follow-up is needed to further evaluate the effect of tacrolimus on SCr
levels in patients with LN.
It is known that different kidney pathological types of LN respond differentially to drug therapy.
In this study, except for class IV+V LN, the response rate in the tacrolimus group was numerically
higher than that in the IVCY group for all other pathological classes , especially class V LN, which had
a response rate of 68.4%. This is consistent with findings from the study by Mok et al,25 in which
patients with class V LN who received tacrolimus as initial therapy had a higher response rate at 6
months than those treated with MMF (100% vs 75%).25 These results highlight the beneficial effects
of tacrolimus on membranous LN, which should be further elucidated in future large-sample,
multicenter studies.
Most patients in both treatment groups experienced TEAEs, but the majority were mild or
moderate in severity. No unexpected safety findings were reported, and the incidence and type of
TEAEs observed was expected in the patient population. Of note, the proportion of patients in whom
infection was reported as a study drug–related serious TEAE was numerically lower in the tacrolimus
group (8.9%) than in the IVCY group (16.2%). Although not assessed in this study, the potential for
longer term treatment-related adverse effects should be considered when selecting the most
appropriate initial therapy in patients with LN. In this context, the apparent lack of ovarian toxic
effects with tacrolimus is an advantage over IVCY, which has been shown to be associated with an
increased risk of premature ovarian failure in patients with SLE.11,12 However, whether tacrolimus is
associated with long-term kidney toxic effects in LN—as has been suggested in transplantation—may
also be a consideration.30,31 Long-term follow-up of Chinese patients with LN is needed in the future
to evaluate the long-term effect of CNIs on kidney function.
Overall, the findings from our study are encouraging for use of tacrolimus as LN initial therapy
in clinical practice. Although long-term data are limited, tacrolimus was also recently shown to be
effective and well tolerated as maintenance therapy over a period of 5 years in a large population of
patients with LN in real-world clinical settings in Japan.32

Limitations
This study has limitations, including the open-label design and the short duration of follow-up (24
weeks). Furthermore, it was not designed to assess whether tacrolimus can be steroid sparing and
mitigate the adverse effects associated with long-term steroid treatment. In addition, subgroup
analyses should be interpreted with caution because of the small number of patients in some groups.
Furthermore, only Chinese patients were included, which may limit application of the findings to
non-Asian populations. However, the study population can be considered representative of the
general population of patients with LN, as it predominantly comprised women of child-bearing age.

Conclusions
In this study, initial therapy with oral tacrolimus in combination with corticosteroids appears to be
effective and have a more favorable safety profile in Chinese patients with LN. Our findings add to
the increasing evidence supporting a role for tacrolimus as an alternative to IVCY for initial therapy
of LN.18-22,25

ARTICLE INFORMATION
Accepted for Publication: January 29, 2022.
Published: March 30, 2022. doi:10.1001/jamanetworkopen.2022.4492

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2022
Zheng Z et al. JAMA Network Open.
Corresponding Authors: Zhangsuo Liu, MD, Department of Nephrology, The First Affiliated Hospital of
Zhengzhou University, No. 1 Jianshe Rd, Zhengzhou, Henan, China, 450052 (zhangsuoliu@sina.com); Zhihong
Liu, MD, National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of
Medicine, 305 East Zhongshan Rd, Nanjing 210016, China (liuzhihong@nju.edu.cn).
Author Affiliations: Department of Rheumatology, The First Affiliated Hospital of Zhengzhou University,
Zhengzhou, China (Zheng); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing
University School of Medicine, Nanjing, Jiangsu, China (H. Zhang, Zhihong Liu); Department of Nephrology, The
People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China (Peng); Department of Nephrology,
Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
(C. Zhang); Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical
University, Nanjing, Jiangsu, China (Xing); Department of Nephrology, Tongji Hospital affiliated with Tongji
Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (G. Xu); Renal Division,
Department of Medicine, West China Hospital of Sichuan University, Kidney Research Institute, Chengdu, Sichuan,
China (Fu); Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai,
China (Ni); Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University,
Hangzhou, Zhejiang, China (J. Chen); Department of Nephrology, The First Hospital of Jilin University, Changchun,
Jilin, China (Z. Xu); Renal Division, Department of Medicine, Peking University First Hospital, Institute of
Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of
Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, and Peking-Tsinghua Center for
Life Sciences, Beijing, China (Zhao); Department of Nephrology, The Second Hospital of Hebei Medical University,
Shijiazhuang, Hebei, China (S. Li); Department of Nephrology, Liuzhou Worker’s Hospital, Liuzhou, Guangxi, China
(Huang); Department of Nephrology, Second Hospital, Jilin University, Changchun, Jilin, China (Miao); Department
of Nephrology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (X. Chen);
Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
(B. Liu); Department of Nephrology, Shenzhen Hengsheng Hospital, Shenzhen, Guangdong, China (He);
Department of Nephrology, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China (J. Li);
Astellas Pharma China, Inc., (L. Liu, Kadeerbai); Department of Nephrology, The First Affiliated Hospital of
Zhengzhou University, Zhengzhou, China (Zhangsuo Liu).
Author Contributions: Mr Kadeerbai had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis. Drs Zheng and H. Zhang contributed equally to
this paper.
Concept and design: Zheng, H. Zhang, Peng, Xing, Ni, Z. Xu, Zhao, S. Li, Huang, X. Chen, B. Liu, Zhangsuo Liu,
Zhihong Liu.
Acquisition, analysis, or interpretation of data: Zheng, H. Zhang, Peng, C. Zhang, G. Xu, Fu, J. Chen, S. Li, Huang,
Miao, X. Chen, He, J. Li, L. Liu, Kadeerbai, Zhangsuo Liu.
Drafting of the manuscript: Zheng, H. Zhang, G. Xu, Fu, Ni, Z. Xu, Huang, B. Liu, Zhangsuo Liu.
Critical revision of the manuscript for important intellectual content: Zheng, H. Zhang, Peng, C. Zhang, Xing, J. Chen,
Zhao, S. Li, Huang, Miao, X. Chen, He, J. Li, L. Liu, Kadeerbai, Zhangsuo Liu, Zhihong Liu.
Statistical analysis: Zheng, H. Zhang, Fu, Huang, Kadeerbai.
Obtained funding: B. Liu.
Administrative, technical, or material support: Zheng, H. Zhang, Peng, C. Zhang, G. Xu, Fu, Ni, J. Chen, Z. Xu, X.
Chen, B. Liu, He, Zhangsuo Liu, Zhihong Liu.
Supervision: Zheng, Peng, Zhao, S. Li, Huang, X. Chen, L. Liu, Zhangsuo Liu.
Conflict of Interest Disclosures: Dr L. Liu and Mr Kadeerbai reported being employees of Astellas Pharma China.
All authors report nonfinancial support from Astellas Pharma, Inc. during the conduct of the study. No other
disclosures were reported.
Funding/Support: This study was sponsored by Astellas Pharma China, Inc.
Role of the Funder/Sponsor: The sponsor was involved with the design and conduct of the study, analysis and
interpretation of the data, review and approval of the manuscript, and the decision to submit the manuscript for
publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: The authors would like to acknowledge the following individuals for their contributions
to the collection of study data: Li Zuo, MD (Department of Nephrology, Peking University People’s Hospital), Yan
Xu, MD (Department of Nephrology, The Affiliated Hospital of Qingdao University), Liang Wang, MD (Department

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 JAMA Network Open | Rheumatology Effect of Tacrolimus vs Intravenous Cyclophosphamide on Response in Patients With Lupus Nephritis

of Nephrology, WuXi People’s Hospital), Rong Li, MD (Department of Nephrology, The Second Hospital of Tianjin
Medical University), Detian Li, MD (Department of Nephrology, Shengjing Hospital of China Medical University),
Yinghong Liu, MD (Department of Nephrology, The Second Xiangya Hospital of Central South University), Tianjun
Guan, MD (Department of Nephrology, Zhongshan Hospital Xiamen University), Ying Li, MD (Department of
Nephrology, The Third Hospital Of Hebei Medical University), Yonggui Wu, MD (Department of Nephrology, The
First Affiliated Hospital of Anhui Medical University), Hequn Zou, MD (Department of Nephrology, The Third
Affiliated Hospital of Southern Medical University), Lihua Wang, MD (Department of Nephrology, The Second
Hospital of Shanxi Medical University), Hongguang Zheng, MD (Department of Nephrology, PLA Northern Theater
General Hospital), Juiyang Zhao, MD (Department of Nephrology, The Second Hospital of Dalian Medical
University), Guisen Li, MD (Department of Nephrology, Sichuan Provincial People’s Hospital), Xiangcheng Xiao, MD
(Department of Nephrology, Xiangya Hospital Central South University), Yunhua Liao, MD (Department of
Nephrology, The First Affiliated Hospital of Guangxi Medical University) and Jun Xue, MD (Department of
Nephrology, Huashan Hospital Affiliated to Fudan University). The authors would also like to acknowledge Zhu
Jing, MS (Astellas Pharma China, Inc), for contributions to the statistical programming used for analysis of study
data, and Jing Wu, MM (Astellas Pharma China, Inc), for coordination and communication in the publication
development process. Jennifer Coward, BSc, assisted in drafting the manuscript under the direction of the
authors, for Cello Health MedErgy, which provided editorial support throughout the manuscript’s development.
Written permission was obtained from all people acknowledged. Writing and editorial support was funded by
Astellas Pharma, Inc.
Additional Information: Informed patient consent form notified patients that anonymized data will be published.
The study was conducted in accordance with the principles of the Declaration of Helsinki and the Internal
Conference on Harmonisation Guidance for Good Clinical Practice. The study protocol and all study-related
materials were approved by the independent ethics committee or institutional review board at each study site.
Patients provided written informed consent to participate prior to any study-related procedures.

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SUPPLEMENT 1.
Trial Protocol and Statistical Analysis Plan

SUPPLEMENT 2.
eTable 1. Study Exclusion Criteria
eTable 2. Sensitivity and Subgroup Analyses of the Primary Efficacy End Point
eTable 3. Study Drug Compliance and Exposure (Safety Population)

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eTable 4. Results of Sensitivity Analyses of Response Rate at Week 24

eTable 5. Subgroup Analyses: Response Rate by Different Pathological Types of LN at Week 24
eTable 6. Mean SCr Level and Mean Change from Baseline to Week 24
eFigure 1. Mean (SE) Change from Baseline to Week 24 in SLEDAI Score
eFigure 2. Mean (SE) Change from Baseline to Week 24 in Serum C3 and Serum C4

SUPPLEMENT 3.
Data Sharing Statement

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