From the Guidelines
Management of a patient with lupus nephritis on immunosuppressants who develops pyelonephritis requires prompt antibiotic therapy while carefully adjusting immunosuppressive medications, as outlined in the updated 2019 recommendations by the European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) 1. When managing lupus nephritis with immunosuppressants and pyelonephritis, it is crucial to balance the treatment of the infection with the need to control lupus activity.
- Start with broad-spectrum antibiotics like ceftriaxone 1-2g IV daily or piperacillin-tazobactam 3.375g IV every 6 hours, then narrow based on urine culture results, to effectively treat the pyelonephritis.
- Complete a 10-14 day antibiotic course for pyelonephritis in immunocompromised patients, as recommended for such cases.
- Regarding immunosuppressants, temporarily reduce or hold mycophenolate mofetil or azathioprine during the acute infection, but maintain a low dose of prednisone (typically 10-20mg daily) to prevent lupus flare, as suggested by the updated recommendations 1.
- Hydroxychloroquine should be continued at the usual dose, as it is beneficial for maintaining control of lupus symptoms.
- Monitor renal function closely with daily creatinine measurements and urinalysis, ensuring adequate hydration and antipyretics as needed.
- After resolution of the infection, gradually reintroduce immunosuppressants to previous doses under close monitoring, to prevent exacerbation of lupus nephritis. This approach is supported by the latest guidelines and balances the need to treat the infection effectively while preventing exacerbation of lupus nephritis, as severe infections can trigger lupus flares and worsen kidney function, while excessive immunosuppression can impair the body's ability to clear the infection 1.
From the Research
Lupus Nephritis Management
- Lupus nephritis (LN) is a common complication in patients with systemic lupus erythematosus, and early diagnosis and treatment can improve renal outcomes 2.
- The treatment of LN is largely determined based on the histological class present on the renal biopsy specimen, with Class III and IV LN requiring immunosuppressive therapy 2.
Immunosuppressant Treatment
- Several therapeutic approaches are available for the induction and maintenance immunosuppression of LN, including cyclophosphamide, mycophenolate mofetil (MMF), and calcineurin inhibitors 3, 4.
- MMF has emerged as a first-line treatment for LN due to its better safety profile compared to cyclophosphamide 5.
- A low-dose combination of MMF and tacrolimus has been shown to be more efficacious than intravenous pulse cyclophosphamide in inducing remission of LN in some patients 5.
Treatment Patterns and Outcomes
- Real-world LN treatment patterns have shown that around 30% of patients are unresponsive to treatment, and many patients switch or re-initiate induction therapy within 12 months 6.
- The cumulative incidence of switching between induction therapies was 24.6% at 12 months, while 59.6% of patients converted to maintenance therapy at 12 months 6.
- Oral corticosteroid use decreased during follow-up, but a significant proportion of patients remained on high doses at 12 and 24 months 6.
Pyelonephritis Considerations
- There is limited information available on the specific management of pyelonephritis in patients with LN on immunosuppressant therapy.
- However, it is essential to consider the increased risk of infections, including pyelonephritis, in patients with LN on immunosuppressant therapy, and to monitor and manage these risks accordingly 3, 4.