*2.3.4 Cyclophosphamide*

Cyclophosphamide is an alkylating agent. It crosslinks DNA and results in the death of activated lymphocytes and protects glomeruli [56, 66]. It modulates the expression of T and B cell activation markers [67]. It has been demonstrated in a meta-analysis that there is a decreased risk of end-stage renal disease when cyclophosphamide is applied as standard of care therapy for lupus nephritis [68]. Cyclophosphamide has potential side effects, which include leukopenia, infection risk, bladder toxicity and increased risk of malignancy [69]. Consequently, cyclophosphamide is used as an induction treatment for severe lupus [64, 70] and is replaced by other agents, such as MMF and azathioprine for long-term maintenance treatment.
