From the Guidelines
Lupus nephritis is a serious kidney complication of systemic lupus erythematosus (SLE), occurring in approximately 20-60% of SLE patients, as reported in the most recent guideline by KDIGO in 2024 1.
Relationship between Lupus Nephritis and SLE
The relationship between lupus nephritis and SLE is direct, with lupus nephritis being a manifestation of SLE affecting the kidneys. The immune system creates antibody-antigen complexes that deposit in the kidney's filtering units (glomeruli), causing inflammation and potentially leading to kidney damage or failure if left untreated.
Classification and Treatment
Lupus nephritis is classified into six types based on severity and location of kidney damage. Treatment typically involves immunosuppressive medications like:
- Corticosteroids (prednisone, starting at 0.5-1 mg/kg/day)
- Cyclophosphamide (500-1000 mg/m² monthly)
- Mycophenolate mofetil (2-3 g daily)
- Rituximab for resistant cases Maintenance therapy often continues for 2-3 years with lower doses of these medications. Additionally, hydroxychloroquine (200-400 mg daily) is recommended for all SLE patients to reduce flares, as suggested by the 2019 update of the joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations 1.
Management and Monitoring
Blood pressure control with ACE inhibitors or ARBs is crucial to protect kidney function. Regular monitoring of kidney function through blood tests, urine analysis, and occasionally kidney biopsies is essential for managing this condition effectively. Early detection and aggressive treatment of lupus nephritis significantly improve long-term kidney outcomes and patient survival, as emphasized by the American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis 1.
Long-term Outcomes
Despite recent advances in therapy, some patients may eventually progress to end-stage renal disease (ESRD) and require dialysis treatment or kidney transplantation. Both dialysis and transplantation in SLE have rates for long-term patient or graft survival comparable with those in non-diabetic/non-SLE patients, as reported in the EULAR recommendations for the management of systemic lupus erythematosus 1.
From the Research
Definition and Overview of Lupus Nephritis
- Lupus nephritis is a common complication of systemic lupus erythematosus (SLE) that carries significant morbidity and mortality 2, 3, 4, 5, 6.
- It is a form of glomerulonephritis that constitutes one of the most severe organ manifestations of SLE 6.
- Early recognition and treatment of lupus nephritis are essential to reduce the long-term risk of renal failure and improve patient outcomes 2, 3, 4, 5, 6.
Relationship between Lupus Nephritis and SLE
- Most patients with SLE who develop lupus nephritis do so within 5 years of an SLE diagnosis, and in many cases, lupus nephritis is the presenting manifestation resulting in the diagnosis of SLE 6.
- Lupus nephritis is associated with considerable morbidity and mortality, and despite advances in treatment, 10-15% of SLE patients with lupus nephritis progress to end-stage renal disease 5.
- The treatment of lupus nephritis usually involves immunosuppressive therapy, typically with mycophenolate mofetil or cyclophosphamide and with glucocorticoids 2, 3, 4, 5, 6.
Treatment and Management of Lupus Nephritis
- Mycophenolate mofetil has emerged as a first-line treatment for lupus nephritis due to its better safety profile compared to cyclophosphamide 2.
- Azathioprine and mycophenolate are used for maintaining remission of lupus nephritis, and cyclophosphamide is no longer used in that phase 4, 5.
- Novel treatment options are being explored, including biologics and combination therapies, but more research is needed to determine their efficacy and safety 2, 3, 6.
- Early diagnosis and treatment are crucial to improve outcomes in patients with SLE, and treatment should be tailored to the individual patient's needs and disease severity 2, 3, 4, 5, 6.