From the Guidelines
The initial hospital treatment for lupus nephritis should involve a combination of high-dose glucocorticoids and immunosuppressive medications, with options including mycophenolic acid analogs, low-dose intravenous cyclophosphamide, belimumab, or a combination of these, as recommended by the most recent guidelines. When considering the treatment options, it's crucial to prioritize the patient's kidney function and the severity of the disease.
- The treatment should be tailored to the individual patient, taking into account factors such as the presence of nephrotic-range proteinuria, adverse prognostic factors, and plans for pregnancy.
- According to the KDIGO 2024 clinical practice guideline for the management of lupus nephritis 1, the initial therapy for active Class III or IV lupus nephritis should include glucocorticoids plus any one of the following: mycophenolic acid analogs, low-dose intravenous cyclophosphamide, belimumab and either mycophenolic acid analogs or low-dose intravenous cyclophosphamide, or mycophenolic acid analogs and a calcineurin inhibitor when kidney function is not severely impaired.
- The 2019 update of the joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis 1 also provides guidance on the treatment targets, use of glucocorticoids and calcineurin inhibitors, and management of end-stage kidney disease.
- The choice of treatment should be based on the most recent and highest-quality evidence, with consideration of the patient's specific needs and circumstances.
- In general, the treatment of lupus nephritis aims to achieve a complete response, defined as proteinuria <0.5-0.7 g/24 hours with (near-) normal glomerular filtration rate, by 12 months, and to prevent long-term kidney damage and other complications.
- Hydroxychloroquine should be continued or initiated as background therapy, and supportive care should include blood pressure control and management of comorbidities.
- The treatment should be regularly monitored and adjusted as needed to ensure the best possible outcomes for the patient.
From the Research
Initial Hospital Treatment for Lupus Nephritis
The initial hospital treatment for lupus nephritis typically involves immunosuppression with corticosteroids and cyclophosphamide, which is considered the standard of care 2.
Treatment Options
- Immunosuppressive therapy with cyclophosphamide and corticosteroids is commonly used for Class III and IV lupus nephritis 3.
- Mycophenolate mofetil (MMF) is a new immunosuppressive agent that has shown efficacy in patients with serious disease recalcitrant to conventional cytotoxic agents 4.
- Retinoids, such as all-trans-retinoic acid, have been reported to be effective in treating lupus nephritis, especially in patients who do not respond to traditional immunosuppressive agents 5.
- Biologic agents, including Abetimus sodium, Rituximab, Epratuzumab, Abatacept, Belimumab, Tocilizumab, and Infliximab, are being developed as immunomodulatory therapies for lupus nephritis, targeting specific pathways that contribute to the inflammatory response 6.
Considerations
- The treatment of lupus nephritis is largely determined based on the histological class present on the renal biopsy specimen 3.
- Early diagnosis and effective treatment can improve renal outcomes in patients with lupus nephritis 3.
- Management of lupus nephritis should be individualized for each patient based on their risk-benefit profile 3.