From the Guidelines
Treatment of lupus nephritis should involve a two-phase approach, starting with induction therapy using mycophenolate mofetil (MMF 2–3 g/day) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), combined with glucocorticoids, to achieve complete response by 12 months 1. The goal of treatment is to achieve complete response, defined as proteinuria <0.5–0.7 g/24 hours with (near-) normal glomerular filtration rate, by 12 months, which can be extended in patients with baseline nephrotic-range proteinuria.
- Induction therapy options include:
- MMF 2–3 g/day or mycophenolic acid (MPA) at equivalent dose
- Low-dose intravenous CY (500 mg × 6 biweekly doses)
- Both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3–0.5 mg/kg/day)
- Maintenance therapy should follow with MMF or azathioprine, and no or low-dose (<7.5 mg/day) glucocorticoids, with the choice of agent depending on the initial regimen and plans for pregnancy.
- Hydroxychloroquine is recommended with regular ophthalmological monitoring, and assessment for kidney and extra-renal disease activity, and management of comorbidities is also recommended 1. In cases of non-responding disease, switching of induction regimens or using rituximab are recommended, and for pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin–angiotensin–aldosterone blockade, MMF in combination with glucocorticoids is preferred 1.
From the Research
Treatment Options for Lupus Nephritis
- The treatment of lupus nephritis (LN) typically involves immunosuppressive therapy, with options including mycophenolate mofetil (MMF), cyclophosphamide (CYC), and glucocorticoids 2, 3, 4, 5, 6.
- The APLAR consensus recommends a combination of glucocorticoids with CYC, MMF, or calcineurin inhibitors as first-line options for initial treatment of LN 2.
- For patients at significant risk of disease progression and renal function deterioration, an upfront combination of immunosuppressive drugs and biological agents may be considered 2.
- MMF has been shown to be superior to azathioprine in decreasing the incidence of treatment failure during maintenance therapy 3, 4.
- The choice between MMF and CYC as induction therapy may depend on factors such as race and initial urine protein level, with MMF being superior in increasing serum complement C3 and complete remission, but CYC being better in lowering urine protein in Asian patients or those with initial urine protein levels less than 4g/day 5.
Maintenance Therapy
- Maintenance therapy should continue for at least 3 years to reduce the risk of renal flares 2.
- Lower dose MMF and azathioprine are options for maintenance therapy, but MMF maintenance should follow induction by the same drug 2.
- Prednisolone or equivalent should be maintained at a dose of 5mg/day or less 2.