From the Guidelines
The initial treatment for lupus nephritis should involve a combination of corticosteroids and immunosuppressive medications, with mycophenolate mofetil (MMF) at 2-3 g/day or low-dose intravenous cyclophosphamide (CY) as first-line options, according to the most recent guidelines 1. The choice of initial treatment depends on the severity of the disease and the presence of adverse prognostic factors.
- For patients with class III-IV lupus nephritis, MMF or low-dose CY are recommended as first-line options, with a target dose of MMF at 2-3 g/day and CY at 0.5-0.75 g/m² monthly for 6 months 1.
- In patients with adverse prognostic factors, such as nephritic urine sediment and impaired renal function, high-dose intravenous CY can be considered 1.
- Glucocorticoids, such as prednisone, should be used at a starting dose of 0.3-0.5 mg/kg/day, with a goal of reducing the dose to ≤7.5 mg/day by 3-6 months 1.
- Hydroxychloroquine (HCQ) is recommended for all patients with lupus nephritis, at a daily dose not exceeding 5 mg/kg actual body weight, to reduce the risk of kidney flares and improve long-term outcomes 1. Regular monitoring of kidney function, urine protein levels, and blood counts is essential to assess response and detect side effects.
- Supportive care, including blood pressure control with ACE inhibitors or ARBs, should be provided to reduce proteinuria and protect kidney function 1. The treatment approach should be individualized based on the patient's specific needs and response to therapy, with the goal of inducing remission and preserving kidney function.
- The use of calcineurin inhibitors, such as tacrolimus, may be considered in certain cases, particularly in patients with nephrotic-range proteinuria 1. Overall, the initial treatment of lupus nephritis requires a comprehensive approach that takes into account the severity of the disease, the presence of adverse prognostic factors, and the need for supportive care to optimize outcomes.
From the Research
Initial Treatment for Lupus Nephritis
The initial treatment for lupus nephritis typically involves a combination of immunosuppressive medications. According to the 2024 APLAR Consensus on the Management of Lupus Nephritis 2, the recommended first-line options include:
- Glucocorticoids (GCs) with cyclophosphamide (CYC)
- Glucocorticoids (GCs) with mycophenolate mofetil (MMF)
- Glucocorticoids (GCs) with calcineurin inhibitors (CNIs)
Combination Therapies
Some studies suggest that combination therapies may be effective in treating lupus nephritis. For example, a systematic review of rituximab use as induction therapy for lupus nephritis found that rituximab in combination with cyclophosphamide or mycophenolate mofetil resulted in complete renal response (CRR) or partial renal response (PRR) in 66% of patients 3.
Steroid Use
The use of steroids, such as prednisone, is common in the treatment of lupus nephritis. A study on mycophenolate mofetil in the treatment of lupus nephritis found that the use of mycophenolate mofetil allowed for a significant reduction in the dose of steroids 4. Another study found that high-dose prednisone combined with mycophenolate mofetil was effective in treating lupus nephritis, but noted that data on the long-term preservation of renal function were limited 5.
Treatment Considerations
Treatment considerations for lupus nephritis may vary depending on the individual patient and the severity of the disease. The APLAR consensus recommends that subsequent or maintenance therapy should continue for at least 3 years to reduce the risk of renal flares 2. Additionally, the use of biological agents, such as rituximab, may be considered in patients at significant risk of disease progression and renal function deterioration 2.