Understanding American Indian tribal college student knowledge, attitudes, beliefs, and behaviors surrounding alternative tobacco products.

OBJECTIVES: To examine knowledge, attitudes, beliefs, and behaviors about alternative tobacco products among American Indian tribal college students. PARTICIPANTS: One hundred and five tribal college students. METHODS: Focus groups, one interview, and demographic surveys. RESULTS: Tobacco use varied across the sample with 35.2% of the participants being users of ENDS products and 29.5% were cigarette smokers. Overall, participants viewed electronic nicotine delivery systems and chewing tobacco as primary examples of alternative tobacco products and described a generational divide between alternative and conventional tobacco product use. Alternative tobacco products were not considered suitable for use in traditional contexts. CONCLUSIONS: Previously successful cessation programs in this population have relied on cultural tailoring related to traditional tobacco use in American Indian communities. Our findings suggest that this strategy may be less effective for addressing alternative tobacco use. Reliance on the importance of family relationships may prove more impactful in future programming.

Leveraging National Data and Regional Innovations to Right-Size Tobacco Treatment Policy for Behavioral Health in a Midwestern State.

BACKGROUND: People with mental health (MH) and substance use disorders (SUD) have high rates of tobacco use and tobacco-related mortality. They want to stop smoking and studies have shown they can quit, but few behavioral health facilities provide tobacco treatment. The purpose of this paper is to describe how a midwestern statewide behavioral health collaboration used regional data to pinpoint strengths and weaknesses in tobacco treatment trends, identified policies in neighboring states that were associated with high rates of tobacco treatment, and worked with state leaders to implement these policies to enhance treatment. METHODS: We used publicly available data from 2 SAMHSA annual national surveys of MH/SUD facilities to describe tobacco treatment services and policies in behavioral health facilities in Kansas and 3 neighboring states (Missouri, Nebraska and Oklahoma). We interviewed neighboring state leaders to identify policies they had implemented to boost tobacco recovery services in behavioral health. We collaborated with our state behavioral health agency to encourage adoption of similar policies. RESULTS: Using 7 years of survey data (2014-2020), rates for screening, counseling, and medications for tobacco dependence were highest in Oklahoma and Missouri facilities. Oklahoma had the highest percentages of facilities reporting smoke-free campuses. In all states, rates of tobacco service provision and smoke-free campuses were lower among SUD facilities than in MH facilities. State leaders associated several policies with high performance, including (a) requiring programs contracting with the state to conduct screening, provide counseling, and adopt smoke-free campuses (Oklahoma and Missouri); (b) state-based collection of tobacco treatment service provision data (Oklahoma); (c) providing facilities with free NRT for clients (Oklahoma); (d) setting benchmarks for service provision (Oklahoma); (e) comprehensive Medicaid coverage of cessation medications (Missouri). Upon review of these findings, Kansas behavioral health officials adopted a 2-year process to implement similar policies and are integrating tobacco treatment requirements into the state Certified Community Behavioral Health Clinic program. CONCLUSIONS: Summarizing and sharing freely-available data across states laid the groundwork for cross-border networking and policy change. State and federal agencies should integrate these policies into contracts and block grants to reduce tobacco-related disparities among individuals with behavioral health conditions.

Using Bayesian hierarchical models for controlled post hoc subgroup analysis of clinical trials: application to smoking cessation treatment in American Indians and Alaska Natives.

Clinical trials powered to detect subgroup effects provide the most reliable data on heterogeneity of treatment effect among different subpopulations. However, pre-specified subgroup analysis is not always practical and post hoc analysis results should be examined cautiously. Bayesian hierarchical modelling provides grounds for defining a controlled post hoc analysis plan that is developed after seeing outcome data for the population but before unblinding the outcome by subgroup. Using simulation based on the results from a tobacco cessation clinical trial conducted among the general population, we defined an analysis plan to assess treatment effect among American Indians and Alaska Natives (AI/AN) enrolled in the study. Patients were randomized into two arms using Bayesian adaptive design. For the opt-in arm, clinicians offered a cessation treatment plan after verifying that a patient was ready to quit. For the opt-out arm, clinicians provided all participants with free cessation medications and referred them to a Quitline. The study was powered to test a hypothesis of significantly higher quit rates for the opt-out arm at one-month post randomization. Overall, one-month abstinence rates were 15.9% and 21.5% (opt-in and opt-out arm, respectively). For AI/AN, one-month abstinence rates were 10.2% and 22.0% (opt-in and opt-out arm, respectively). The posterior probability that the abstinence rate in the treatment arm is higher is 0.96, indicating that AI/AN demonstrate response to treatment at almost the same probability as the whole population.

Everyday discrimination for American Indian tribal college students enrolled in the Internet All Nations Breath of Life program.

OBJECTIVE: Identify factors associated with perceived discrimination, including depression, body image satisfaction, body mass index (BMI), social support, stress, and self-reported social status. PARTICIPANTS: A total of 249 American Indian tribal college students. METHODS: Students were recruited for an Internet-based smoking cessation program. A total of 249 students answered the Everyday Discrimination Scale questions to assess perceived discrimination. We conducted bivariate analyses to determine potential significant associations between perceived discrimination and health outcomes at baseline. RESULTS: We found 63% of the sample reported racial discrimination. Among those who reported moderate/severe depression, 87% reported discrimination. Among those who were not satisfied with their body image, 70% reported racial discrimination. CONCLUSION: Reports of racial discrimination are highly prevalent among our participants. We found reports of discrimination are significantly associated with depression and dissatisfaction with body image. Our study highlights a high priority population that perceives racial discrimination, potentially increasing their risk for adverse health outcomes.

Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

BACKGROUND: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN). METHODS: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m2. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. RESULTS: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study. CONCLUSIONS: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m2.

Pilot Testing All Nations Snuff Out Smokeless (ANSOS): A Culturally Tailored Smokeless Tobacco Cessation Program for American Indians.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

Cardiovascular Outcomes Associated With Adult Electronic Cigarette Use.

Electronic cigarettes (E-Cigs) have been advertised as a safer alternative to smoking. However, E-Cigs use, like smoking, delivers ultra-small aerosol particles, which may be associated with cardiovascular disease. This study aimed to look into the association between E-Cigs use and cardiovascular disease outcomes. The study involved self-reported data from 16,855 participants from the National Health Interview Survey data from years 2014, 2016, 2017, and 2018. Results from the logistic regression analysis report E-Cigs users had higher odds of having myocardial infarction (OR 4.09, 95% CI [1.29, 12.98], P<0.05) when compared to non-users. Dual users had higher odds of myocardial infarction (OR 5.44, 95% CI [2.90, 10.22], P<0.05), stroke (OR 2.32, 95% CI [1.44, 3.74], P<0.05), and coronary artery disease (OR 2.27, 95% CI [1.37, 2.44], P<0.05) when compared to non-users.

Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up.

BACKGROUND: The aim of the present study was to compare the surgical outcomes of retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and open retropubic radical prostatectomy (ORP). METHODS: We included patients with clinically localized prostate cancer who underwent RS-RARP or ORP and met our inclusion criteria. We compared the perioperative, oncological, and continence outcomes between both surgical approaches. Continence function was assessed using the validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Continence was defined as using 0-1 safety pad per day. Biochemical recurrence (BCR) was defined as two consecutive rises in serum PSA more than 0.2 ng/mL. Events of local recurrence, distant metastasis, and cancer death were reported and compared using Kaplan-Meier survival analysis. RESULTS: Between 1 June 2013 and 1 October 1 2016, 184 men were enrolled, of whom 125 underwent RS-RARP and 59 underwent ORP. Baseline demographic and pathological characteristics were similar between both groups (P>0.05). Patients in RS-RARP group had significantly lower blood loss, fewer transfusion rates, lower VAS score, and shorter hospital stay than patients in ORP group (P<0.05). Major complications (≥grade 3b) did not differ between both groups (P=0.121). Positive surgical margins were 28.8% and 24.8% in ORP and RS-RARP, respectively (P=0.494). The BCR free-survival rates in ORP and RS-RARP at 1-year was 87.3% and 92.3%, respectively (Log-rank, P=0.740). At 1-, 6-, and 12-month after surgery, 42.4%, 79.7%, and 84.7% of men undergoing ORP were continent, compared with 72.8%, 90.4%, and 92% undergoing RS-RARP, respectively. Men in RS-RARP group achieved faster recovery of urinary continence compared to men in ORP group (Log-rank, P=0.001). CONCLUSIONS: RS-RARP had better perioperative outcomes and faster recovery of urinary continence compared with ORP. Short-term oncological outcomes were comparable between both surgical approaches.

Baseline characteristics of American Indian smokeless tobacco users participating in two pilot cessation studies.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

Non-toxic fragment of botulinum neurotoxin type A and monomethyl auristatin E conjugate for targeted therapy for neuroendocrine tumors.

Surgical resection is the only cure for neuroendocrine tumors (NETs). However, widespread metastases have already occured by the time of initial diagnosis in many cases making complete surgical removal impossible. We developed a recombinant heavy-chain receptor binding domain (rHCR) of botulinum neurotoxin type A that can specifically target synaptic vesicle 2 (SV2), a surface receptor abundantly expressed in multiple neuroendocrine tumors. Expression of neuroendocrine differentiation markers chromogranin A (CgA) and achaete-scute complex 1 (ASCL1) were signficantly reduced when treated with rHCR. rHCR conjugated to the antimitotic agent monomethyl auristatin E (MMAE) significantly suppressed proliferation of pancreatic carcinoid (BON) and medullary thyroid cancer cells (MZ) at concentrations of 500 and 300 nM respectively, while no growth suppression was observed in pulmonary fibroblasts and cortical neuron control cell lines. In vivo, rHCR-MMAE significantly reduced tumor volume in mouse xenografts with no observed adverse effects. These data suggest recombinant HCR (rHCR) of BoNT/A preferentially targets neuroendocrine cancer without the neurotoxicity of the full BoNT/A and that SV2 is a specific and promising target for delivering drugs to neuroendocrine tumors.

Antibiotic decision making in surgical intensive care: a qualitative analysis.

BACKGROUND: Antibiotic use in hospitals is high, particularly in surgical specialty and intensive care units. Antimicrobial stewardship programmes (ASPs) are increasingly intervening in antibiotic use by surgeons and intensivists. However, there is limited information on the features which characterize antibiotic decision making in the surgical intensive care unit (SICU), an area in hospital practice where critically ill surgery patients can be kept under close observation. AIM: To explore the features which characterize antibiotic decision making in the SICU. METHODS: A total of 160 h of ethnographic observation and 10 semi-structured interviews were conducted at two teaching hospitals in the USA. Data were analysed using thematic coding. FINDINGS: Three key characteristics of SICU practice with regard to antibiotic use were identified: (1) physical proximity makes SICU clinicians acutely aware of changes in patient status; (2) communication of patient status relies on active involvement by SICU clinicians; (3) SICU clinicians have contested and variable autonomy over antibiotic decisions. CONCLUSIONS: Antibiotic decision making in the SICU is a complex process involving multiple clinician teams with varying levels of physical proximity to and autonomy over patient cases. This study found that the SICU clinician team has increased physical proximity to patient cases but little autonomy over antibiotic decisions. If these characteristics are not considered, antimicrobial stewardship (AMS) interventions may have diminished success in addressing high levels of the antibiotic use in the SICU.

Transrectal ultrasound-guided targeted biopsy of transition zone prostate cancer under cognitive registration with prebiopsy MRI and sonographic findings.

AIM: To evaluate retrospectively the diagnostic usefulness of transrectal ultrasound (TRUS)-guided targeted biopsy (TB) for transition zone (TZ) prostate cancer (PCa) in patients with prebiopsy magnetic resonance imaging (MRI). MATERIALS AND METHODS: A consecutive series of 38 patients who underwent TRUS-guided TB of TZ lesions were evaluated. TB (mean core number, 2.4±0.6; range, 2-4) was performed by a single experienced radiologist under cognitive registration between prebiopsy MRI and TRUS. Tumour echogenicity on TRUS and Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) scoring on MRI for targeted TZ lesions were assessed. The interrupted midline sign was defined as a focal lesion traversing the midline of the TZ leading to discontinuity of the midline on both MRI and TRUS. TZ PCa with a Gleason score of 7 or greater was defined as clinically significant PCa (csPCa). RESULTS: The cancer detection rate of TRUS-guided TB for TZ lesions was 78.9% (30/38) for any PCa and 42.1% (16/38) for csPCa. Echogenicity of TZ PCa on TRUS was various and half did not show low echogenicity (low, 50%; intermediate, 26.7%; and high, 23.3%). The interrupted midline sign was identified in 50% (19/38) of patients, which was highly predictive of TZ PCa (94.7%, 18/19). CONCLUSION: TRUS-guided TB under cognitive registration based on prebiopsy MRI findings is useful to detect TZ PCa. Knowledge of the sonographic features of TZ PCa may help to target TZ PCa accurately under cognitive registration.

One-Time Education Sessions to Help American Indian Smokeless Tobacco Users Quit.

American Indian (AI) smokeless tobacco use rates are the highest of all racial/ethnic groups within the United States. Despite this, no effective cessation program currently exists that acknowledges the cultural significance of tobacco among many American Indian tribal nations. Participants were smokeless tobacco users, over 18 years of age, and were recruited through community partners. We modified the All Nations Snuff Out Smokeless Tobacco group-based program to be delivered as a one-time education session intervention. This was delivered to 80 participants and follow-up data was collected by self-report at 6-months. The mean age of participants was 35 and most were male (70%). A majority (69%) grew up on a AI reservation; the mean age of first smokeless tobacco use was 16 years of age. Of program completers reached for 6-month post baseline, 46% reported 0 days of SLT use; 13.5% of participants reduced; while 36% reported continued daily use. In intention to treat analysis those lost to follow-up are considered current users, the quit rate was 12.5% and among those who were still using, 4.0% reduced their use. In this study, a one-time education session intervention was effective for those who prefer an individual based approach to quitting SLT use. Follow up strategies to increase participant retention at 6-months should be explored.

Removal of Nasal Silicone Implant and the Impact of Subsequent Capsulectomy.

BACKGROUND: Little is known about contributory factors of unremoved periimplant capsule causing nasal deformities after postrhinoplasty silicone implant extraction. This study investigated the impact of retained capsule causing contracture deformity and effect of subsequent capsulectomy in preventing and correcting the deformity. METHODS: A total of 103 patients underwent secondary surgery for silicone implant removal and grafted cartilage between May of 2015 and June of 2017. Among them, 67 patients without septal extension graft or open wound and with 8-week or more follow-up were analyzed retrospectively. All operations were approached with an intranasal incision. Three procedures were performed: (1) removal of implant plus tip graft only (n = 12), (2) removal of implant plus tip graft plus subtotal capsulectomy (n = 47), and (3) removal of implant plus tip graft plus subtotal capsulectomy in patients with contraction and thick capsule (n = 8). Preremoval/postremoval of nasal bridge length index and nasolabial angle were measured with the lateral view. RESULTS: In group 1, nasal bridge length index decreased by 6.2 percent and nasolabial angle increased by 5.7 percent. In group 2, nasal bridge length index increased by 2.5 percent and nasolabial angle decreased by 2.2 percent. In group 3, nasal bridge length index increased by 8.6 percent and nasolabial angle decreased by 7.9 percent. CONCLUSIONS: For patients undergoing surgical removal of a nasal silicone implant with or without cartilage, a concomitant capsulectomy is required to prevent potential contractures and to minimize tip deformity. Capsulectomy can release and lengthen the contracted nose without septal extension or derotation grafting. Dorsal skin irregularity did not occur regardless of whether capsulectomy was performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Serum Free Light Chain Assay in Monoclonal Gammopathic Manifestations.

BACKGROUND: Serum free light chain assay is used in the diagnosis and monitoring of monoclonal gammopathic manifestations. For the kappa (κ)/lambda (λ) ratio, there is a 36% false-positive rate in patients without monoclonal gammopathic manifestations and a 30% false-negative rate in patients with monoclonal gammopathic manifestations. This study was undertaken to address the higher false-negative rate in λ chain-associated monoclonal lesions. METHODS: Results of serum protein electrophoresis, serum immunofixation electrophoresis, and serum free light chain assays were reviewed retrospectively. The results for serum free light chains in cases of intact immunoglobulin monoclonal gammopathic manifestations only were analyzed. RESULTS: Concentrations of involved serum free light chains were significantly higher in κ chain-associated lesions than in λ chain-associated lesions. The concentration of uninvolved light chains was significantly higher in λ chain-associated lesions. CONCLUSIONS: κ light chains are present in significantly greater abundance than are λ chains in their respective monoclonal lesions. Moreover, κ and λ light-chain levels are not comparable for similar quantitative levels of monoclonal immunoglobulins. The findings warrant a reconsideration of the role of serum free light chain concentrations and involved to uninvolved serum free light chain ratio in designation of myeloma-defining conditions and other diagnostic criteria based on serum free light chain assay.

BLTR1 in Monocytes Emerges as a Therapeutic Target For Vascular Inflammation With a Subsequent Intimal Hyperplasia in a Murine Wire-Injured Femoral Artery.

Given the importance of high-mobility group box 1 (HMGB1) and 5-lipoxygenase (5-LO) signaling in vascular inflammation, we investigated the role of leukotriene signaling in monocytes on monocyte-to-macrophage differentiation (MMD) induced by HMGB1, and on vascular inflammation and subsequent intimal hyperplasia in a mouse model of wire-injured femoral artery. In cultured primary bone marrow-derived cells (BMDCs) stimulated with HMGB1, the number of cells with macrophage-like morphology was markedly increased in association with an increased expression of CD11b/Mac-1, which were attenuated in cells pre-treated with Zileuton, a 5-LO inhibitor as well as in 5-LO-deficient BMDCs. Of various leukotriene receptor inhibitors examined, which included leukotriene B4 receptors (BLTRs) and cysteinyl leukotriene receptors (cysLTRs), the BLTR1 inhibitor (U75302) exclusively suppressed MMD induction by HMGB1. The importance of BLTR1 in HMGB1-induced MMD was also observed in BMDCs isolated from BLTR1-deficient mice and BMDCs transfected with BLTR1 siRNA. Although leukotriene B4 (LTB4) had minimal direct effects on MMD in control and 5-LO-deficient BMDCs, MMD attenuation by HMGB1 in 5-LO-deficient BMDCs was significantly reversed by exogenous LTB4, but not in BLTR1-deficient BMDCs, suggesting that LTB4/BLTR1-mediated priming of monocytes is a prerequisite of HMGB1-induced MMD. In vivo, both macrophage infiltration and intimal hyperplasia in our wire-injured femoral artery were markedly attenuated in BLTR1-deficient mice as compared with wild-type controls, but these effects were reversed in BLTR1-deficient mice transplanted with monocytes from control mice. These results suggest that BLTR1 in monocytes is a pivotal player in MMD with subsequent macrophage infiltration into neointima, leading to vascular remodeling after vascular injury.

Peripheral T cell lymphoma, not otherwise specified (PTCL-NOS). A new prognostic model developed by the International T cell Project Network.

Different models to investigate the prognosis of peripheral T cell lymphoma not otherwise specified (PTCL-NOS) have been developed by means of retrospective analyses. Here we report on a new model designed on data from the prospective T Cell Project. Twelve covariates collected by the T Cell Project were analysed and a new model (T cell score), based on four covariates (serum albumin, performance status, stage and absolute neutrophil count) that maintained their prognostic value in multiple Cox proportional hazards regression analysis was proposed. Among patients registered in the T Cell Project, 311 PTCL-NOS were retained for study. At a median follow-up of 46 months, the median overall survival (OS) and progression-free survival (PFS) was 20 and 10 months, respectively. Three groups were identified at low risk (LR, 48 patients, 15%, score 0), intermediate risk (IR, 189 patients, 61%, score 1-2), and high risk (HiR, 74 patients, 24%, score 3-4), having a 3-year OS of 76% [95% confidence interval 61-88], 43% [35-51], and 11% [4-21], respectively (P < 0·001). Comparing the performance of the T cell score on OS to that of each of the previously developed models, it emerged that the new score had the best discriminant power. The new T cell score, based on clinical variables, identifies a group with very unfavourable outcomes.

Outcomes of multitarget therapy using mycophenolate mofetil and tacrolimus for refractory or relapsing lupus nephritis.

Objectives Outcomes of systemic lupus erythematosus (SLE) have significantly improved over the years. However, when there is major organ involvement, the outcomes can still be unfavorable. Outcomes of multitarget therapy using mycophenolate mofetil (MMF) and tacrolimus in patients with SLE who were refractory to standard therapy were assessed. Methods We retrospectively reviewed the Hanyang BAE lupus cohort to identify patients with biopsy-confirmed lupus nephritis (classes III, IV, or V) who failed to either achieve complete response with standard induction therapy or those who had a lupus flare after achieving a complete response with conventional induction therapy and subsequently were switched to multitarget combination therapy with MMF and tacrolimus. Outcomes, including renal response, proteinuria, glomerular filtration rate, serum albumin, anti-dsDNA antibody level, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and complements, were assessed at six and 12 months. Results Twenty-nine patients, including 12 who failed to achieve a complete response at 12 months after initial conventional induction therapy and 17 with lupus flare after achieving a complete response at 12 months and treated with multitarget therapy, were included in the analysis. At six months, 53.9% of the patients showed a response, with 15.4% of patients showing a complete response and 38.5% of patients showing a partial response. At 12 months, 55.5% of patients exhibited a response (with complete and partial response in 25.9% and 29.6%, respectively). The dosage of steroids was significantly decreased at six months compared with baseline and was maintained at 12 months. Proteinuria, anti-double-stranded DNA antibody positivity, as well as C3 and C4 levels improved after treatment and persisted until 12 months, but were not significant. SLEDAI also improved. Outcomes were significantly better in patients who had a complete response but later had a flare, resulting in the use of multitarget therapy and achieving a subsequent complete response. Conclusions Multitarget therapy with MMF and tacrolimus can be a reasonable option in refractory lupus nephritis patients who failed to show adequate response to conventional induction therapy or who had flares during maintenance therapy. This treatment can help patients achieve a renal response and reduce the use of steroids.